HumanaChoice H5216-316 (PPO) H5216-316-001 2024 Plan Details and Costs (2024)

HumanaChoice H5216-316 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H5216-316-001

Oklahoma 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 Oklahoma 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

Coverage Details
Monthly plan premium$28.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$4,400.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visit
Out-of-Network:

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $5.00

Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $30.00

Inpatient hospital care
Out-of-Network:
$325.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Urgent care
Urgent Care:
Copayment for Urgent Care $60.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $120.00

Emergency room visit
Emergency Care:
Copayment for Emergency Care $120.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $120.00
Copayment for Worldwide Emergency Transportation $120.00

Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $300.00
Copayment for Medicare Covered Ambulance Services - Air $300.00

Health Care Services and Medical Supplies

HumanaChoice H5216-316 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-316 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $20.00
Prior Authorization Required for Chiropractic Services

Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0.00
Coinsurance for Medicare-covered Diabetic Supplies 10% to 20%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10.00
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)

Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
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 $0.00 to $100.00
Copayment for Medicare-covered Lab Services $0.00 to $60.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $300.00
Copayment for Medicare-covered Therapeutic Radiological Services $30.00
Copayment for Medicare-covered X-Ray Services $0.00 to $125.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services

Home health care
Out-of-Network:

Home Health Services:
Coinsurance for Medicare Covered Home Health 40%

Mental health inpatient care
Out-of-Network:
$325.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
Prior Authorization Required for Outpatient Mental Health Services

Outpatient services/surgery
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 40%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40%

Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
Prior Authorization Required for Outpatient Substance Abuse Services

Over-the-counter items
Out-of-Network:

Over-The-Counter (OTC) Items:
Coinsurance for Non-Medicare Covered Over-The-Counter (OTC) Items 50%
Maximum Plan Benefit of $60.00

Podiatry services
Out-of-Network:

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $50.00

Skilled Nursing Facility (SNF) care
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 40%

Dental Benefits

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

Coverage Details
Dental careIn 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, fluoride treatment, 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.$2,500 combined maximum benefit coverage amount per year for all 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, fluoride treatment, 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.$2,500 combined maximum benefit coverage amount per year for all 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.

Coverage Details
Vision benefits
Out-of-Network:

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $50.00
Coinsurance for Medicare Covered Eye Exams 40%
Coinsurance for Medicare Covered Eyewear 40%
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $0.00
Copayment for Non-Medicare Covered Eyewear $0.00

Hearing Benefits

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

Coverage Details
Hearing benefits
Out-of-Network:

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $50.00
Non-Medicare Covered Hearing Services:
Coinsurance for Non-Medicare Covered Hearing Exams 50%
Coinsurance for Non-Medicare Covered Hearing Aids 50%

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.

Coverage Details
Preventive services and health/wellness education programs
Out-of-Network:

Medicare-covered Zero Dollar Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0.00
Coinsurance for Medicare Covered Medicare-covered Preventive Services 40%

When reviewing Oklahoma 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 Oklahoma that offer similar benefits at similar or lower prices than the plan above. Call 1-855-298-6309 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents
  • Summary of benefits
  • Evidence of coverage
  • Star ratings

Oklahoma Counties Served

Adair Blaine Bryan Caddo Carter Cherokee Choctaw Coal Comanche Craig Delaware Dewey Garfield Garvin Haskell Hughes Jackson Johnston Kay Kiowa Latimer Le Flore Mccurtain Mcintosh Murray Muskogee Noble Nowata Okfuskee Ottawa Pawnee Payne Pittsburg Pontotoc Pushmataha Sequoyah Stephens Woodward

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

Back to plans in Oklahoma

HumanaChoice H5216-316 (PPO) H5216-316-001 2024 Plan Details and Costs (2024)
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