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HumanaChoice H5216-027 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-027 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-027 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-027 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Fredericksburg, Northern Virginia, & Roanoke areas. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-027 (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about HumanaChoice H5216-027 (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For HumanaChoice H5216-027 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $71.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $350.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $14000.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $14000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The HumanaChoice H5216-027 (PPO) plan has a $350 deductible for prescription drugs. After the deductible is met, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For the initial coverage phase, you'll pay a copay of $12 for preferred generic drugs at preferred pharmacies, and 50% coinsurance for preferred brand drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-027 (PPO) plan offers a range of benefits with varying costs. You'll find no copays for many services, including preventive services, home health, and several dental and vision services. The plan has copays for services like inpatient hospital stays ($399), emergency services ($110), primary care visits ($15), and hearing exams ($45). You may also encounter coinsurance for services like dialysis (20%), medical equipment (10-20%), and home infusion services (0-20%).
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered under the HumanaChoice H5216-027 (PPO) plan. For Inpatient Hospital-Acute, you pay a $399 copay for days 1-6, and no copay for days 7-90, and for Inpatient Hospital Psychiatric, you pay a $399 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute have no copay, while Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and Additional days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services for the HumanaChoice H5216-027 (PPO) plan includes coverage for outpatient hospital services with a copay between $0 and $450, observation services with a $399 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a copay between $45 and $100 for both individual and group sessions, and outpatient blood services with no copay. Prior authorization is required for all services.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-027 (PPO) plan with a $80 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by HumanaChoice H5216-027 (PPO). Medicare-covered ground and air ambulance services have a $315 copay with no coinsurance, while transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Services, are covered by the HumanaChoice H5216-027 (PPO) plan. Emergency Services have a $110 copay, Urgently Needed Services have a $45 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $110 copay.
Primary Care See details
The HumanaChoice H5216-027 (PPO) plan covers primary care physician services with a $15 copay, chiropractic services with a $15 copay, occupational therapy services with a $25 copay, physician specialist services with a $45 copay, mental health specialty services with a $45 copay, other health care professional services with a copay between $15 and $45, psychiatric services with a $45 copay, physical therapy and speech-language pathology services with a $25 copay, additional telehealth benefits with a copay between $0 and $45, and opioid treatment program services with a copay between $45 and $100. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include Medicare-covered preventive services and annual physical exams with no copay. Additional preventive services, kidney disease education services, other preventive services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit are covered with no copay. Health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
Hearing exams are covered with a $45 copay, and routine hearing exams have no copay. Prescription hearing aids are covered with a copay between $699 and $999, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
The HumanaChoice H5216-027 (PPO) plan covers vision services, including eye exams, with a copay ranging from $0 to $45. Eyewear, including contact lenses and eyeglasses (lenses and frames), is also covered with no copay, though eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services include Medicare Dental Services with a $45 copay, Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), and Other Preventive Dental Services with no copay. Fluoride Treatment, Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered. Adjunctive General Services are covered with no copay.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. You will pay a $35 copay for Medicare Part B Insulin Drugs, with a coinsurance between 0% and 20% depending on the specific drug.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-027 (PPO) plan, with a coinsurance of 20%. Prior authorization is required for this benefit.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered. DME has a 20% coinsurance and requires authorization, while Prosthetic Devices and Medical Supplies have a 20% coinsurance, with no copay. Diabetic Supplies have a 10-20% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the HumanaChoice H5216-027 (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $120.00, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $325.00, and Therapeutic Radiological Services have a copay of at most $45.00 and a coinsurance of 20%. Outpatient X-Ray Services have a copay of $15.00.
Home Health Services See details
Home Health Services are covered under the HumanaChoice H5216-027 (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover any of the sub-services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-027 (PPO) plan, but require prior authorization. There is no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered for SNF, and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes acupuncture and a meal benefit. Acupuncture has a $45 copay per visit for up to 20 treatments per year, and the meal benefit has no copay.
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