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HumanaChoice H5216-288 (PPO) - H5216-288-000

3.5 out of 5 stars* for plan year 2025

$24.60

Monthly Premium

HumanaChoice H5216-288 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H5216-288-000

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

$24.60

Monthly Premium

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

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$24.60
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$275.00
Out-of-pocket maximum$4,950.00
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 $0
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $30
Inpatient hospital careIn-Network:

Acute Hospital Services:
$295 per day for days 1 to 7
$0 per day for days 8 to 90
Prior Authorization Required for Acute Hospital Services
Urgent care
Urgent Care:
Copayment for Urgent Care $55

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $125
Emergency room visit
Emergency Care:
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 transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $315

Air Ambulance:
Copayment for Air Ambulance Services $315
Prior Authorization Required for Air Ambulance

Health Care Services and Medical Supplies

HumanaChoice H5216-288 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-288 (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 $40
Diabetes supplies, training, nutrition therapy and monitoring
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 17% to 30%
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-rays
Out-of-Network:

Medicare Covered Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests
$5 to $110
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
30%
Copayment for Medicare Covered Lab Services
$5 to $55
Coinsurance for Medicare Covered Lab Services
30%
Copayment for Medicare Covered Diagnostic Radiological Services $40 to $100
Coinsurance for Medicare Covered Diagnostic Radiological Services 30%
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Copayment for Medicare Covered Outpatient X-Ray Services $5 to $55
Coinsurance for Medicare Covered Outpatient X-Ray Services 30%
$100 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$30 OP Diag Proc & Tests - SPC$55 OP Diag Proc & Tests - UCC$100 Sleep Study (Fac Based) - OPH$30 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_
Home health care
Out-of-Network:

Medicare Covered Home Health Services:
Coinsurance for Medicare Covered Home Health 50%
Mental health inpatient care
Out-of-Network:

Psychiatric Hospital Services:
$295 per day for days 1 to 7
$0 per day for days 8 to 90
Mental health outpatient care
Out-of-Network:

Medicare Covered Mental Health Services:
Copayment for Medicare Covered Individual Sessions $40
Copayment for Medicare Covered Group Sessions $40
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $30 to $700
Prior Authorization Required for Outpatient Hospital Services
$295 Diag Colonoscopy - OPH$100 Mental Health - OPH$700 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 $245 to $600
Prior Authorization Required for Ambulatory Surgical Center Services
$245 Diag Colonoscopy - ASC$600 Surgery Svcs - ASC_
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $25 to $100
Copayment for Medicare-covered Group Sessions $25 to $100
Prior Authorization Required for Outpatient Substance Abuse Services
$100 OP Substance Abuse Care - OPH$25 OP Substance Abuse Care - SPC_
Podiatry services
Out-of-Network:

Medicare Covered Podiatry Services:
Copayment for Medicare Covered Podiatry Services $40
Skilled Nursing Facility (SNF) careIn-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

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 scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
$0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment, scaling for moderate inflammation up to 1 every 3 years.
$0 copayment for bridge recementation, bridges-pontic, complete dentures, crown recementation, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years.
$0 copayment for bridges-crown up to 2 every 5 years.
$0 copayment for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime.
$0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
$0 copayment for adjustments to dentures, denture rebase, denture reline, denture repair, emergency diagnostic exam, tissue conditioning up to 1 per year.
$0 copayment for emergency treatment for pain, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year.
$1,500 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.
Out of Network
$0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
$0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment, scaling for moderate inflammation up to 1 every 3 years.
$0 copayment for bridge recementation, bridges-pontic, complete dentures, crown recementation, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years.
$0 copayment for bridges-crown up to 2 every 5 years.
$0 copayment for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime.
$0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
$0 copayment for adjustments to dentures, denture rebase, denture reline, denture repair, emergency diagnostic exam, tissue conditioning up to 1 per year.
$0 copayment for emergency treatment for pain, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year.
$1,500 combined maximum benefit coverage amount per year for all diagnostic/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 $40
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 care
Out-of-Network:

Medicare Covered Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $40

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 H5216-288 (PPO) offers prescription drug coverage, with an annual drug deductible of $275.00 (excludes Tiers 1 and 2)

Coverage & Cost
Coverage
Cost
Annual drug deductible$275.00 (excludes Tiers 1 and 2)
Tier 1
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $10.00
Tier 2
  • Standard retail $5.00
  • Preferred mail order $5.00
  • Standard mail order $20.00
Annual drug deductible$275.00 (excludes Tiers 1 and 2)
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
Annual drug deductible$275.00 (excludes Tiers 1 and 2)
Tier 1
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $30.00
Tier 2
  • Standard retail $15.00
  • Preferred mail order $0.00
  • Standard mail order $60.00

When reviewing Connecticut 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 Connecticut that offer similar benefits at similar or lower prices than the plan above. Call 1-877-822-4889 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Connecticut 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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