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HumanaChoice H5216-177 (PPO)

H5216 - 177 - 0
3.5 out of 5 stars (3.5 / 5)

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HumanaChoice H5216-177 (PPO) is a Medicare Advantage Plan by Humana.

This page features plan details for 2025 HumanaChoice H5216-177 (PPO) H5216 – 177 – 0 available in Maine.

Locations

HumanaChoice H5216-177 (PPO) is offered in the following locations.

Androscoggin County, Maine
Aroostook County, Maine
Cumberland County, Maine

Click to see more locations

Plan Overview

HumanaChoice H5216-177 (PPO) offers the following coverage and cost-sharing.

Insurer:Humana
Health Plan Deductible:$405 annual deductible
MOOP:$8,950 In and Out-of-network
$4,950 In-network
Drugs Covered:Yes

Ready to sign up for HumanaChoice H5216-177 (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 H5216-177 (PPO) has a monthly premium of $28.00. 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
$185.00 $0.40 $27.60 $ $
Please Note:
  • 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 H5216-177 (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $300.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

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 DLIS Full
$27.60$0.00

Initial Coverage Phase

After you pay your $300.00 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 $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

HumanaChoice H5216-177 (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply, Authorization Required)
    • Out-of-Network: No Coins – 0.00 Copay (Limits Apply, Authorization Required)
  • Restorative Services
    • In-Network: No Coins – 25.00 Copay (Authorization Required)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: No Coins – 0.00 Copay
  • Oral Exams
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: No Coins – 0.00 Copay
  • Other Diagnostic Dental Services
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: No Coins – 0.00 Copay
  • Other Preventive Dental Services
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: No Coins – 0.00 Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: No Coins – 0.00 Copay

Diagnostic procedures/lab services/imaging

  • Lab services
    • In-Network: $0-55 copay (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: $20-55 copay or 30% coinsurance (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $25-300 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0-80 copay (Authorization Required)
  • Lab services
    • Out-of-Network: $20-55 copay or 30% coinsurance (Authorization Required)
  • Outpatient x-rays
    • In-Network: $0-125 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: $50 copay or 30% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: $20-55 copay or 30% coinsurance (Authorization Required)

Doctor visits

  • Primary
    • Out-of-Network: $20 copay per visit
  • Specialist
    • Out-of-Network: $50 copay per visit
  • Primary
    • In-Network: $0 copay
  • Specialist
    • In-Network: $30 copay per visit

Emergency care/Urgent care

  • Urgent care
    • $55 copay per visit (always covered)
  • Emergency
    • $125 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • Out-of-Network: $50 copay (Authorization Required)
  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • In-Network: $30 copay (Authorization Required)

Ground ambulance

    • In-Network: $315 copay
    • Out-of-Network: $315 copay

Health plan deductible

    • $405 annual deductible

Hearing

  • Hearing aids
    • Out-of-Network: $699-999 copay (Limits Apply)
  • Hearing aids OTC
    • Not covered
  • Fitting/evaluation
    • In-Network: $0 copay (Authorization Required)
    • Out-of-Network: $0 copay (Authorization Required)
  • Hearing aids
    • In-Network: $699-999 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • Out-of-Network: $50 copay (Authorization Required)
    • In-Network: $30 copay (Authorization Required)

Inpatient hospital coverage

    • In-Network: $295 per day for days 1 through 6
      $0 per day for days 7 through 90
      $0 per day for days 91 and beyond (Authorization Required)
    • Out-of-Network: $495 per day for days 1 through 7
      $0 per day for days 8 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $8,950 In and Out-of-network
      $4,950 In-network

Medical equipment/supplies

  • Diabetes supplies
    • Out-of-Network: 20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 14% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 14% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: $0 copay or 10% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Other Part B drugs
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit
    • In-Network: $30 copay (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $30 copay (Authorization Required)
  • Outpatient individual therapy visit
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Inpatient hospital – psychiatric
    • In-Network: $295 per day for days 1 through 6
      $0 per day for days 7 through 90 (Authorization Required)
    • Out-of-Network: $495 per day for days 1 through 7
      $0 per day for days 8 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $30 copay (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $30 copay (Authorization Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $30-725 copay per visit (Authorization Required)
    • Out-of-Network: 30% coinsurance per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: $0 copay

Rehabilitation services

  • Occupational therapy visit
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • In-Network: $30 copay (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Occupational therapy visit
    • In-Network: $30 copay (Authorization Required)

Skilled Nursing Facility

    • Out-of-Network: 30% per stay (Authorization Required)
    • In-Network: $10 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)

Transportation

    • Not covered

Vision

  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply, Authorization Required)
  • Upgrades
    • Not covered
  • Contact lenses
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Eyeglass frames
    • Not covered
  • Eyeglass lenses
    • Not covered
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Other
    • Not covered
  • Routine eye exam
    • Out-of-Network: $0 copay (Limits Apply, Authorization Required)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply, Authorization Required)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply, Authorization Required)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for HumanaChoice H5216-177 (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

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