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HumanaChoice H5216-289 (PPO)
The Centers for Medicare & Medicaid Services (CMS) publishes annual Star Ratings that reflect how each Medicare Advantage plan performs across a range of metrics, using a system of one to five stars.
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Monthly Premium
HumanaChoice H5216-289 (PPO) is a PPO plan offered by Humana Inc.
Plan ID: H5216-289
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.
Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.
Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.
Learn more about Medicare Advantage plans such as HumanaChoice H5216-289 (PPO) - H5216-289 by Humana Inc. as well as other Medicare Advantage plans available in your area.
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Monthly Premium
Connecticut Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $400 |
| Out of Pocket Max |
In-Network: $5200 Out-of-Network: 6950 |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $2100 |
| Primary Care Doctor Visit | Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered Primary Care Office Visit $10 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $40 Prior Authorization Required for Doctor Specialty Visit |
| Inpatient Hospital Care | Out-of-Network: Acute Hospital Services: $335 per day for days 1 to 7 $0 per day for days 8 to 90 |
| Urgent Care | Urgent Care: Copayment for Urgent Care $50 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $130 |
| Emergency Room Visit | Emergency Care: Copayment for Emergency Care $130 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 $130 Copayment for Worldwide Emergency Transportation $130 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $335 Air Ambulance: Copayment for Air Ambulance Services $335 Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
HumanaChoice H5216-289 (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 | Out-of-Network: Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $50 In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Supplies 10% to 20% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10 |
| Durable Medical Equipment (DME) | Out-of-Network: Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 30% $0 Continuous Glucose Monitor - DME Prov$0 Continuous Glucose Monitor - Pharmacy18% DME - DME Prov18% DME - Pharmacy |
| 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 $85 Copayment for Medicare-covered Lab Services $0 to $50 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services $85 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$40 OP Diag Proc & Tests - SPC$50 OP Diag Proc & Tests - UCC$85 Sleep Study (Fac Based) - OPH$35 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 $780 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 to $125 |
| Home Health Care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $311 per day for days 1 to 7 $0 per day for days 8 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental Health Outpatient Care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $35 Copayment for Medicare-covered Group Sessions $35 |
| Outpatient Services / Surgery | Out-of-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $50 Coinsurance for Medicare Covered Outpatient Hospital Services 30% Copayment for Medicare Covered Ambulatory Surgical Center Services $0 Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30% $0 Diag Colonoscopy - OPH$35 Mental Health - OPH$660 Surgery Svcs - OPH$40 Wound Care - OPH |
| Outpatient Substance Abuse Care | Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $50 Coinsurance for Medicare Covered Individual Sessions 30% Copayment for Medicare Covered Group Sessions $50 Coinsurance for Medicare Covered Group Sessions 30% In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $35 Copayment for Medicare-covered Group Sessions $35 Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter (OTC) Items | Over-the-Counter: $50 quarterly allowance to buy approved over-the-counter health and wellness products available through our OTC Mail Order provider. Unused amount rolls over to the next quarter and expires at the end of the plan year. |
| Podiatry Services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $40 Prior Authorization Required for Podiatry Services Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $50 |
| Skilled Nursing Facility Care | Out-of-Network: Skilled Nursing Facility Services: Coinsurance for Skilled Nursing Facility per Stay 30% |
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 as needed with covered codes per year. |
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 $40 Copayment for Routine Eye Exams $0
$0 Diab Eye Exam - All POTs$40 Vision Svcs (MC) - SPC Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0
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 $100 less than the PLUS network. |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | Out-of-Network: 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 | Out-of-Network: Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
Prescription Drug Costs and Coverage
The HumanaChoice H5216-289 (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $400 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $400 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $400 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $400 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|