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HumanaChoice H5216-177 (PPO)

Humana Inc.
HumanaChoice H5216-177 (PPO) H5216-177 Plan Details
3.5 out of 5 stars

HumanaChoice H5216-177 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-177

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$28.00
Monthly Premium

HumanaChoice H5216-177 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-177

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Humana Inc.
HumanaChoice H5216-177 (PPO) H5216-177 Plan Details
3.5 out of 5 stars

HumanaChoice H5216-177 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-177

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$28.00
Monthly Premium

Maine Counties Served

Franklin York Cumberland Sagadahoc Androscoggin Kennebec Lincoln Waldo Piscataquis Penobscot Hancock Washington Somerset Aroostook Knox

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $300
Out of Pocket Max In-Network: $4950
Out-of-Network: N/A
Initial Coverage Limit $2000
Catastrophic Coverage Limit $2,000
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $20
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $30
Out-of-Network:

Doctor Specialty Visit Services:
Copayment for Medicare Covered Physician Specialist Office Visit $50
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$295 per day for days 1 to 6
$0 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:

Acute Hospital Services:
$495 per day for days 1 to 7
$0 per day for days 8 to 90
Urgent Care
Copayment for Urgent Care $55

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $125
Emergency Room Visit
Copayment for Emergency Care $125
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $125
Copayment for Worldwide Emergency Transportation $125
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $315

Air Ambulance:
Copayment for Air Ambulance Services $315
Prior Authorization Required for Air Ambulance
Prior authorization required
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $315
Copayment for Medicare Covered Ambulance Services - Air $315

Health Care Services and Medical Supplies

HumanaChoice H5216-177 (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $10
Prior Authorization Required for Chiropractic Services
Prior authorization required
Out-of-Network:

Medicare Covered Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 30%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0
Coinsurance for Medicare-covered Diabetic Supplies 10%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0
Out-of-Network:

Medicare Covered Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 20%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 20% to 30%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 14%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Out-of-Network:

Medicare Covered Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 30%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $80
Copayment for Medicare-covered Lab Services $0 to $55
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
$80 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$30 OP Diag Proc & Tests - SPC$55 OP Diag Proc & Tests - UCC$80 Sleep Study (Fac Based) - OPH$25 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $25 to $300
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0 to $125
Prior authorization required
Out-of-Network:

Medicare Covered Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests
$20 to $55
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
30%
Copayment for Medicare Covered Lab Services
$20 to $55
Coinsurance for Medicare Covered Lab Services
30%
Copayment for Medicare Covered Diagnostic Radiological Services $50
Coinsurance for Medicare Covered Diagnostic Radiological Services 30%
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Copayment for Medicare Covered Outpatient X-Ray Services $20 to $55
Coinsurance for Medicare Covered Outpatient X-Ray Services 30%
$80 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$30 OP Diag Proc & Tests - SPC$55 OP Diag Proc & Tests - UCC$80 Sleep Study (Fac Based) - OPH$25 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Prior authorization required
Out-of-Network:

Medicare Covered Home Health Services:
Coinsurance for Medicare Covered Home Health 50%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$295 per day for days 1 to 6
$0 per day for days 7 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:

Psychiatric Hospital Services:
$495 per day for days 1 to 7
$0 per day for days 8 to 90
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $30
Copayment for Medicare-covered Group Sessions $30
Out-of-Network:

Medicare Covered Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $30 to $725
Prior Authorization Required for Outpatient Hospital Services
$250 Diag Colonoscopy - OPH$95 Mental Health - OPH$725 Surgery Svcs - OPH$30 Wound Care - OPH_

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $295
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $200 to $625
Prior Authorization Required for Ambulatory Surgical Center Services
$200 Diag Colonoscopy - ASC$625 Surgery Svcs - ASC_
Prior authorization required
Out-of-Network:

Medicare Covered Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 30%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30%
$250 Diag Colonoscopy - OPH$95 Mental Health - OPH$725 Surgery Svcs - OPH$30 Wound Care - OPH_
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $30 to $95
Copayment for Medicare-covered Group Sessions $30 to $95
Prior Authorization Required for Outpatient Substance Abuse Services
$95 OP Substance Abuse Care - OPH$30 OP Substance Abuse Care - SPC_
Prior authorization required
Out-of-Network:

Medicare Covered Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%
$95 OP Substance Abuse Care - OPH$30 OP Substance Abuse Care - SPC_
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $30
Prior Authorization Required for Podiatry Services
Prior authorization required
Out-of-Network:

Medicare Covered Podiatry Services:
Copayment for Medicare Covered Podiatry Services $50
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$10 per day for days 1 to 20
$214 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
$0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years.
$0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
$0 copayment for emergency diagnostic exam up to 1 per year.
$0 copayment for periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for necessary anesthesia with covered service up to unlimited per year.
$25 copayment per tooth for amalgam and/or composite filling up to 2 per year.
$1,500 combined maximum benefit coverage amount per year for preventive and comprehensive benefits.
Out of Network
$0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years.
$0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
$0 copayment for emergency diagnostic exam up to 1 per year.
$0 copayment for periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for necessary anesthesia with covered service up to unlimited per year.
$25 copayment per tooth for amalgam and/or composite filling up to 2 per year.
$1,500 combined maximum benefit coverage amount per year for preventive and comprehensive benefits.
Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $30
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exam every year
Maximum Plan Benefit of $75 every year

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0
  • Maximum 1 Pair every year
Copayment for Eyeglasses (lenses and frames) $0
  • Maximum 1 Pair every year
Maximum Plan Benefit of $250 every year
Members must use Humana's Medicare Insight Network, a national network of providers, which includes standard or PLUS providers. The allowance for the standard network is $50 less than the PLUS network.
Out-of-Network:

Medicare Covered Eye Exams Services:
Copayment for Medicare Covered Eye Exams $0 to $50
Copayment for Medicare Covered Eyewear $0

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $30
Copayment for Routine Hearing Exams $0
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $699 to $999
  • Maximum 2 Hearing Aids every year

Prior authorization required
Out-of-Network:

Medicare Covered Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $50

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
    • Tobacco use cessation
    Yearly "Wellness" visit
    Out-of-Network:

    Medicare Covered Medicare-covered Preventive Services:
    Copayment for Medicare Covered Medicare-covered Preventive Services $0

    Prescription Drug Costs and Coverage

    The HumanaChoice H5216-177 (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $300 (excludes Tiers 1, 2 and 3) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $300 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $10.00
    Generic
    • Preferred cost-share mail order $5.00
    • Standard retail $5.00
    • Standard mail order $20.00
    Preferred Brand
    • Preferred cost-share mail order $47.00
    • Standard retail $47.00
    • Standard mail order $47.00
    Annual Drug Deductible $300 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Preferred cost-share mail order N/A
    • Standard retail N/A
    • Standard mail order N/A
    Generic
    • Preferred cost-share mail order N/A
    • Standard retail N/A
    • Standard mail order N/A
    Preferred Brand
    • Preferred cost-share mail order N/A
    • Standard retail N/A
    • Standard mail order N/A
    Annual Drug Deductible $300 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $30.00
    Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $15.00
    • Standard mail order $60.00
    Preferred Brand
    • Preferred cost-share mail order $131.00
    • Standard retail $141.00
    • Standard mail order $141.00
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