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HumanaChoice H5216-457 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-457 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-457 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-457 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2026 to people living in Select Counties in MT. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-457 (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 H5216-457 (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 H5216-457 (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 $230.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $400.00 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 H5216-457 (PPO) Medicare prescription drug plan features an annual drug deductible of $400. For Tier 1 preferred generic drugs, members pay no copay for a 1-month or 3-month supply at standard pharmacies and through preferred mail order. Tier 2 generic drugs are also highly affordable, featuring a $5 copay for a 1-month supply, and no copay for a 3-month supply when filled via preferred mail order. Tier 3 preferred brand drugs require a $47 copay for a 1-month supply, which drops to a $131 copay for a 3-month supply through preferred mail order. Higher-tier medications are subject to coinsurance rather than flat copays, with Tier 4 non-preferred drugs requiring 50% coinsurance. Tier 5 specialty drugs require 28% coinsurance for a 1-month supply across standard pharmacies and mail order options.
Additional Benefits
The HumanaChoice H5216-457 (PPO) plan offers robust medical coverage featuring no copay and no coinsurance for primary care visits, mental health services, and annual preventive physicals. If you require specialist visits, a $55 copay applies, while inpatient hospital stays require a daily copay of $535 for the first five days of acute care with no copay for subsequent days. Emergency room visits have a $130 copay, which is waived if you are admitted within 24 hours, and urgent care visits require a $50 copay. This plan also includes valuable supplemental coverage, offering routine vision, hearing, and dental exams with no copay and no coinsurance. Dental services feature an annual maximum benefit of $1,250, while prescription hearing aids require a copay between $299 and $599. Additionally, home health services are covered with no copay, and skilled nursing facility stays have no copay for the first 20 days.
Inpatient Hospital See details
Inpatient hospital services under HumanaChoice H5216-457 (PPO) are covered with no coinsurance, requiring a $535 daily copay for days 1-5 of acute stays (no copay for days 6 and beyond) and a $465 daily copay for days 1-5 of psychiatric stays (no copay for days 6-90). Prior authorization is required for these stays, and certain services like upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice H5216-457 (PPO) offers outpatient services with no coinsurance, featuring a copay of $0 to $535 for outpatient hospital services and a $535 copay per stay for observation services. There is no copay for ambulatory surgical center or outpatient blood services, while outpatient substance abuse sessions have a copay ranging from $0 to $35.
Partial Hospitalization See details
HumanaChoice H5216-457 (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 H5216-457 (PPO) covers ambulance services with no coinsurance, requiring a $335 copay for ground ambulance and a $1,250 copay for air ambulance. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
HumanaChoice H5216-457 (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $50 copay with no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $130 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-457 (PPO) offers primary care physician visits, mental health specialty services, and psychiatric services with no copay and no coinsurance. Specialist visits require a $55 copay, physical and occupational therapy cost a $45 copay, and telehealth benefits range from no copay to a $55 copay, all with no coinsurance, while podiatry and chiropractic services are not covered.
Preventive Services See details
HumanaChoice H5216-457 (PPO) preventive services are partially covered, offering annual physicals, kidney education, glaucoma screenings, diabetes self-management training, digital rectal exams, EKGs, and memory fitness with no copay and no coinsurance. Uncovered sub-services include health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, smoking cessation counseling, disease management, telemonitoring, remote access, home modifications, and counseling.
Hearing Services See details
Hearing services are partially covered by HumanaChoice H5216-457 (PPO), which features Medicare-covered exams for a $55 copay and no coinsurance, plus annual routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are covered for a $299 to $599 copay and no coinsurance (up to two per year), but inner ear, outer ear, over-the-ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-457 (PPO) offers partially covered vision services, including one routine eye exam per year with no copay and no coinsurance, up to a $75 maximum plan benefit. Eyewear is also covered with no copay and no coinsurance up to a $250 annual limit, though upgrades, separate frames or lenses, and other eye exams are not covered.
Dental Services See details
HumanaChoice H5216-457 (PPO) features partially covered dental services with a $1,250 annual maximum benefit, offering Medicare-covered dental services for a $55 copay and no coinsurance, and other covered preventive and comprehensive dental services with no copay and no coinsurance. Fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-457 (PPO) covers Home Infusion bundled Services with no copay, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other drugs require no coinsurance to 20% coinsurance, while Part B insulin carries a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by HumanaChoice H5216-457 (PPO) with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
HumanaChoice H5216-457 (PPO) covers medical equipment, offering durable medical equipment, prosthetic devices, and medical supplies with a 20% coinsurance and no copay. Diabetic supplies feature a 10% to 20% coinsurance with no copay, while diabetic therapeutic shoes and inserts require a $10 copay and applicable coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by HumanaChoice H5216-457 (PPO) with prior authorization, featuring no copay for lab services and outpatient X-rays. Diagnostic procedures have no coinsurance and a $0 to $95 copay, while diagnostic radiological services start at a $0 copay and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the HumanaChoice H5216-457 (PPO) plan with no copay and no coinsurance. Prior authorization is required before you can receive these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under HumanaChoice H5216-457 (PPO) with no coinsurance and require prior authorization, though some services are covered while standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by HumanaChoice H5216-457 (PPO) with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. Under this benefit, there is no copay for days 1 through 20 and days 71 through 100, a $218 daily copay for days 21 through 70, and additional days beyond the standard Medicare limit are not covered.
Other Services See details
HumanaChoice H5216-457 (PPO) partially covers other services, offering acupuncture for up to 20 treatments per year with a $55 copay and no coinsurance, and chronic illness meal benefits with no copay and no coinsurance. Prior authorization is required for both covered benefits, while over-the-counter (OTC) items are not covered.
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