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HumanaChoice H5216-120 (PPO) - H5216-120-000

3.5 out of 5 stars* for plan year 2025

$105.00

Monthly Premium

HumanaChoice H5216-120 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H5216-120-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$105.00

Monthly Premium

Pennsylvania Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Pennsylvania Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Enrollment may be limited to certain times of the year. See why you may be able to enroll.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$105.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$300.00
Out-of-pocket maximum$7,600.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $5
Specialty doctor visitIn-Network:

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

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $350
Urgent care
Urgent Care:
Copayment for Urgent Care $45

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $110
Emergency room visit
Emergency Care:
Copayment for Emergency Care $110
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 $110
Copayment for Worldwide Emergency Transportation $110
Ambulance transportation
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 H5216-120 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-120 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic services
Out-of-Network:

Medicare Covered Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $20
Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:

Medicare Covered Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 10% to 20%
Copayment for Medicare Covered Diabetic Therapeutic Shoes or Inserts $10
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 17%
Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $90
Copayment for Medicare-covered Lab Services $0 to $50
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
$90 OP Diag Proc & Tests - OPH$5 OP Diag Proc & Tests - PCP$30 OP Diag Proc & Tests - SPC$45 OP Diag Proc & Tests - UCC$90 Sleep Study (Fac Based) - OPH$30 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 $0 to $275
Copayment for Medicare-covered Therapeutic Radiological Services $30
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $5 to $90
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental health inpatient care
Out-of-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital per Stay $350
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $30
Copayment for Medicare-covered Group Sessions $30
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $400
Prior Authorization Required for Outpatient Hospital Services
$0 Diag Colonoscopy - OPH$80 Mental Health - OPH$400 Surgery Svcs - OPH$30 Wound Care - OPH_

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $350
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $300
Prior Authorization Required for Ambulatory Surgical Center Services
$0 Diag Colonoscopy - ASC$300 Surgery Svcs - ASC_
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $30 to $80
Copayment for Medicare-covered Group Sessions $30 to $80
Prior Authorization Required for Outpatient Substance Abuse Services
$80 OP Substance Abuse Care - OPH$30 OP Substance Abuse Care - SPC_
Podiatry services
Out-of-Network:

Medicare Covered Podiatry Services:
Copayment for Medicare Covered Podiatry Services $30
Skilled Nursing Facility (SNF) care
Out-of-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$214 per day for days 21 to 100

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
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.
$2,000 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.
$2,000 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, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision care
Out-of-Network:

Medicare Covered Eye Exams Services:
Copayment for Medicare Covered Eye Exams $0 to $30
Copayment for Medicare Covered Eyewear $0

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-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

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Preventive services and health/wellness education programs
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 H5216-120 (PPO) offers prescription drug coverage, with an annual drug deductible of $300.00 (excludes Tiers 1, 2, and 3)

Coverage & Cost
Coverage
Cost
Annual drug deductible$300.00 (excludes Tiers 1, 2, and 3)
Tier 1
  • Standard retail $5.00
  • Preferred mail order $5.00
  • Standard mail order $10.00
Tier 2
  • Standard retail $15.00
  • Preferred mail order $15.00
  • Standard mail order $20.00
Tier 3
  • Standard retail $47.00
  • Preferred mail order $47.00
  • Standard mail order $47.00
Annual drug deductible$300.00 (excludes Tiers 1, 2, and 3)
Tier 1
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
Tier 2
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
Tier 3
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
Annual drug deductible$300.00 (excludes Tiers 1, 2, and 3)
Tier 1
  • Standard retail $15.00
  • Preferred mail order $0.00
  • Standard mail order $30.00
Tier 2
  • Standard retail $45.00
  • Preferred mail order $0.00
  • Standard mail order $60.00
Tier 3
  • Standard retail $141.00
  • Preferred mail order $131.00
  • Standard mail order $141.00

When reviewing Pennsylvania Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Pennsylvania that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Pennsylvania Counties Served

We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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