HumanaChoice H5216-080 (PPO)
H5216 - 080 - 2
(4 / 5)
HumanaChoice H5216-080 (PPO) is a Medicare Advantage Plan by Humana.
This page features plan details for 2022 HumanaChoice H5216-080 (PPO) H5216 – 080 – 2 available in Twin Cities, Rochester, Duluth Areas.
IMPORTANT: This page features the 2022 version of this plan. See the 2025 version using the link below:
No 2025 version found. You can use the location links below to find 2025 plans in your area.
Locations
HumanaChoice H5216-080 (PPO) is offered in the following locations.
Plan Overview
HumanaChoice H5216-080 (PPO) offers the following coverage and cost-sharing.
| Insurer: | Humana |
| Health Plan Deductible: | $0 |
| MOOP: | $6,700.00 |
| Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $350.00 annual deductible only applies to drugs on certain tiers.
Ready to sign up for HumanaChoice H5216-080 (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Premium Breakdown
HumanaChoice H5216-080 (PPO) has a monthly premium of $49.50. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $170.10 | $125.50 | $49.50 | $0.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
HumanaChoice H5216-080 (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $350.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | No |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $49.50 | $39.90 | $30.30 | $20.80 | $11.20 |
Initial Coverage Phase
After you pay your $350.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
30 Day
90 Day
30 Day
90 Day
| Drug Type | Cost Share |
|---|---|
| Generic drugs | 25% |
| Brand-name drugs | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
HumanaChoice H5216-080 (PPO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | Not covered |
| Endodontics: | Not covered |
| Extractions: | In-Network: 50% coinsurance (limits may apply) (authorization required) |
| Extractions: | Out-of-Network: 55-75% coinsurance (limits may apply) (authorization required) |
| Extractions: | Not covered |
| Non-routine services: | Not covered |
| Periodontics: | In-Network: 70% coinsurance (limits may apply) (authorization required) |
| Periodontics: | Out-of-Network: 55-75% coinsurance (limits may apply) (authorization required) |
| Periodontics: | Not covered |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered |
| Restorative services: | In-Network: 50% coinsurance (limits may apply) (authorization required) |
| Restorative services: | Out-of-Network: 55% coinsurance (limits may apply) (authorization required) |
| Restorative services: | Out-of-Network: 55-75% coinsurance (limits may apply) (authorization required) |
Dental (preventive)
| Cleaning: | In-Network: $0 copay (limits may apply) |
| Cleaning: | In-Network: 0-70% coinsurance (limits may apply) |
| Cleaning: | Out-of-Network: 50% coinsurance (limits may apply) |
| Cleaning: | Out-of-Network: 50-75% coinsurance (limits may apply) |
| Dental x-ray(s): | In-Network: $0 copay (limits may apply) |
| Dental x-ray(s): | Out-of-Network: 50-75% coinsurance (limits may apply) |
| Dental x-ray(s): | Out-of-Network: 50% coinsurance (limits may apply) |
| Fluoride treatment: | In-Network: $0 copay (limits may apply) |
| Fluoride treatment: | Out-of-Network: 50-75% coinsurance (limits may apply) |
| Fluoride treatment: | Not covered |
| Oral exam: | In-Network: $0 copay (limits may apply) |
| Oral exam: | Out-of-Network: 50% coinsurance (limits may apply) |
| Oral exam: | Out-of-Network: 50-75% coinsurance (limits may apply) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | In-Network: $35-250 copay (authorization required) |
| Diagnostic radiology services (e.g., MRI): | In-Network: $40-250 copay (authorization required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: 50% coinsurance (authorization required) |
| Diagnostic tests and procedures: | In-Network: $0-95 copay (authorization required) |
| Diagnostic tests and procedures: | In-Network: $0-100 copay (authorization required) |
| Diagnostic tests and procedures: | Out-of-Network: $0 copay or 50% coinsurance (authorization required) |
| Lab services: | In-Network: $0-40 copay (authorization required) |
| Lab services: | In-Network: $0-25 copay (authorization required) |
| Lab services: | Out-of-Network: 50% coinsurance (authorization required) |
| Outpatient x-rays: | In-Network: $15-95 copay (authorization required) |
| Outpatient x-rays: | In-Network: $20-100 copay (authorization required) |
| Outpatient x-rays: | Out-of-Network: 50% coinsurance (authorization required) |
Doctor visits
| Primary: | In-Network: $15 copay per visit |
| Primary: | In-Network: $20 copay per visit |
| Primary: | Out-of-Network: 50% coinsurance per visit |
| Specialist: | In-Network: $50 copay per visit |
| Specialist: | In-Network: $45 copay per visit |
| Specialist: | Out-of-Network: 50% coinsurance per visit |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $15-45 copay or 50% coinsurance per visit (always covered) |
| Urgent care: | $20-50 copay or 50% coinsurance per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | In-Network: $45 copay (authorization required) |
| Foot exams and treatment: | In-Network: $50 copay (authorization required) |
| Foot exams and treatment: | Out-of-Network: 50% coinsurance (authorization required) |
| Routine foot care: | Not covered |
Ground ambulance
| In-Network: $290 copay | |
| Out-of-Network: $290 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | In-Network: $0 copay (authorization required) |
| Fitting/evaluation: | Out-of-Network: $0 copay (authorization required) |
| Hearing aids: | In-Network: $699-999 copay (limits may apply) |
| Hearing aids: | Out-of-Network: $699-999 copay (limits may apply) |
| Hearing exam: | In-Network: $50 copay (authorization required) |
| Hearing exam: | In-Network: $45 copay (authorization required) |
| Hearing exam: | Out-of-Network: 50% coinsurance (authorization required) |
Hospital coverage (inpatient)
| In-Network: $454 per day for days 1 through 4 $0 per day for days 5 through 90 $0 per day for days 91 and beyond (authorization required) | |
| In-Network: $360 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 91 and beyond (authorization required) | |
| Out-of-Network: 50% per stay (authorization required) |
Hospital coverage (outpatient)
| In-Network: $45-250 copay per visit (authorization required) | |
| In-Network: $50-250 copay per visit (authorization required) | |
| Out-of-Network: 50% coinsurance per visit (authorization required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $10,000 In and Out-of-network $6,700 In-network | |
| $8,850 In and Out-of-network $5,900 In-network |
Medical equipment/supplies
| Diabetes supplies: | In-Network: $0 copay or 10-20% coinsurance per item (authorization required) |
| Diabetes supplies: | Out-of-Network: 50% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 17% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 18% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | In-Network: 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 50% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
| Chemotherapy: | Out-of-Network: 50% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | Out-of-Network: 50% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | In-Network: $318 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) |
| Inpatient hospital – psychiatric: | In-Network: $405 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) |
| Inpatient hospital – psychiatric: | Out-of-Network: 50% per stay (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: 50% coinsurance (authorization required) |
| Outpatient group therapy visit: | In-Network: $40 copay (authorization required) |
| Outpatient group therapy visit: | Out-of-Network: 50% coinsurance (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: 50% coinsurance (authorization required) |
| Outpatient individual therapy visit: | In-Network: $40 copay (authorization required) |
| Outpatient individual therapy visit: | Out-of-Network: 50% coinsurance (authorization required) |
Optional supplemental benefits
| Yes |
Preventive care
| In-Network: $0 copay | |
| Out-of-Network: $0 copay or 50% coinsurance |
Rehabilitation services
| Occupational therapy visit: | In-Network: $40 copay (authorization required) |
| Occupational therapy visit: | Out-of-Network: 50% coinsurance (authorization required) |
| Physical therapy and speech and language therapy visit: | In-Network: $40 copay (authorization required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: 50% coinsurance (authorization required) |
Skilled Nursing Facility
| In-Network: $0 per day for days 1 through 20 $184 per day for days 21 through 100 (authorization required) | |
| Out-of-Network: 50% per stay (authorization required) |
Transportation
| Not covered |
Vision
| Contact lenses: | In-Network: $0 copay (limits may apply) (authorization required) |
| Contact lenses: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
| Eyeglass frames: | Not covered |
| Eyeglass lenses: | Not covered |
| Eyeglasses (frames and lenses): | In-Network: $0 copay (limits may apply) (authorization required) |
| Eyeglasses (frames and lenses): | Out-of-Network: $0 copay (limits may apply) (authorization required) |
| Other: | Not covered |
| Routine eye exam: | In-Network: $0 copay (limits may apply) (authorization required) |
| Routine eye exam: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
Optional Benefits
Package #1
| Preventive dental: | Monthly Premium: | $47.60 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $47.60 |
| Comprehensive dental: | Deductible: | N/A |
| Preventive dental: | Monthly Premium: | $32.80 |
| Comprehensive dental: | Monthly Premium: | $32.80 |
Package #2
| Preventive dental: | Monthly Premium: | $47.60 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $47.60 |
| Comprehensive dental: | Deductible: | N/A |
Ready to sign up for HumanaChoice H5216-080 (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST