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HumanaChoice H5216-461 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-461 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-461 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-461 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2026 to people living in Select Counties in New Jersey. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-461 (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 H5216-461 (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 H5216-461 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $31.10. 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 does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $615.00 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 $10000.00 (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 $10000.00 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 H5216-461 (PPO) Medicare prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generic drugs, members have no copay for 1-month and 3-month supplies at standard pharmacies and through preferred mail order. Tier 2 generic drugs cost a $5 copay for a 1-month supply at standard pharmacies, with no copay for a 3-month supply filled via preferred mail order. Tier 3 preferred brand drugs require a $47 copay for a 1-month supply at standard pharmacies and mail order options. Finally, Tier 4 non-preferred drugs incur a 39% coinsurance, while Tier 5 specialty drugs require a 25% coinsurance for a 1-month supply.
Additional Benefits
The HumanaChoice H5216-461 (PPO) plan offers comprehensive coverage featuring no copay for primary care visits, routine preventive services, and home health care. Specialist visits require a $35 copay, while emergency care carries a $115 copay that is waived if you are admitted to the hospital. Inpatient hospital stays require daily copays for the first seven days before dropping to no copay, and skilled nursing facility stays are covered with no copay for the first 20 days. For extra health services, the plan provides up to a $1,000 annual dental benefit and routine vision and hearing exams with no copay. Durable medical equipment and diabetic supplies are covered with coinsurance ranging from 10% to 20% and no copay. Members also benefit from no copay on over-the-counter items and standard laboratory tests.
Inpatient Hospital See details
HumanaChoice H5216-461 (PPO) covers inpatient hospital services with no coinsurance, requiring a $360 daily copay for days 1-7 of acute stays (no copay for days 8 and beyond) and a $295 daily copay for days 1-7 of psychiatric stays (no copay for days 8-90). Prior authorization is required for these services, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services under HumanaChoice H5216-461 (PPO) are covered with no coinsurance, featuring a copay of $0 to $395 for outpatient hospital services, a $360 copay per stay for observation services, and no copay for ambulatory surgical center services. Outpatient substance abuse individual and group sessions require a $35 copay with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization benefits under the HumanaChoice H5216-461 (PPO) plan are covered with a $35.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
HumanaChoice H5216-461 (PPO) covers ground and air ambulance services with a $335 copay and no coinsurance, though prior authorization is required and the copay is not waived upon hospital admission. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
HumanaChoice H5216-461 (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 $40 copay and no coinsurance, while worldwide emergency, urgent care, and emergency transportation services are available with a $115 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-461 (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $35 copay and no coinsurance. Therapy services have a copay of $20 to $35 with no coinsurance, whereas podiatry is not covered, and chiropractic services are only partially covered as routine and other chiropractic services are not covered.
Preventive Services See details
HumanaChoice H5216-461 (PPO) covers preventive services with no copay and no coinsurance, including annual physicals, kidney disease education, glaucoma screenings, diabetes self-management, and memory fitness. However, additional preventive benefits are only 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 care, nutritional benefits, palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, remote access, home modifications, and counseling.
Hearing Services See details
HumanaChoice H5216-461 (PPO) covers Medicare-covered hearing exams with a $35 copay and no coinsurance, while routine exams, fittings, and OTC hearing aids are available with no copay and no coinsurance. Prescription hearing aids are partially covered with a $699 to $999 copay and no coinsurance, though inner ear, outer ear, and over-the-ear models are not covered.
Vision Services See details
HumanaChoice H5216-461 (PPO) vision services are partially covered, offering routine eye exams and select eyewear with no copay and no coinsurance. Covered benefits include one routine eye exam (up to $75) and one pair of contact lenses or eyeglasses per year (up to a combined $200 limit), while other eye exams, separate eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by HumanaChoice H5216-461 (PPO), which features up to a $1,000 annual maximum benefit with no copay and no coinsurance for preventive and comprehensive care like exams, cleanings, and restorative services. Medicare-covered dental services require a $35.00 copay and no coinsurance, while fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-461 (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy may apply. Covered Medicare Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-461 (PPO) plan with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
HumanaChoice H5216-461 (PPO) covers medical equipment, including durable medical equipment (DME) with a 16% coinsurance and no copay, and prosthetics and medical supplies with a 20% coinsurance and no copay. Diabetic supplies are covered with 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes or inserts require a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by HumanaChoice H5216-461 (PPO) with no copay for lab services and outpatient X-rays, and no coinsurance for diagnostic tests which carry a $0 to $100 copay. Diagnostic radiological services have a copay starting at $0, while therapeutic radiological services require a minimum $50 copay and 20% coinsurance.
Home Health Services See details
HumanaChoice H5216-461 (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-461 (PPO) covers Cardiac Rehabilitation Services with no coinsurance, but only some services are covered in practice because cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are not covered and require a $15 copay.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-461 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and while a prior three-day hospital stay is not required, additional days beyond the Medicare-covered limit are not covered.
Other Services See details
HumanaChoice H5216-461 (PPO) provides coverage for select other services, including acupuncture with a $35 copay and no coinsurance for up to 20 treatments per year, and over-the-counter (OTC) items with no copay and no coinsurance. Meal benefits are not covered under this plan's other services benefit.
Get Personalized Help from a licensed insurance agent
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