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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 2026, 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 2026.
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 $60.00. 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 $615.00 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 $13900.00 (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 $13900.00 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 features an annual drug deductible of $615. For Tier 1 preferred generic drugs, there is no copay when using a standard pharmacy or preferred mail order. Tier 2 generic drugs are also highly affordable, costing a $5 copay for a 1-month supply at standard pharmacies and featuring no copay for a 3-month supply through preferred mail order. For Tier 3 preferred brand drugs, you will pay a $47 copay for a 1-month supply at standard pharmacies and mail order options. Higher-tier medications require coinsurance rather than a flat copay, with Tier 4 non-preferred drugs carrying a 41% coinsurance and Tier 5 specialty drugs requiring a 25% coinsurance.
Additional Benefits
The HumanaChoice H5216-027 (PPO) plan offers robust coverage for core medical needs, featuring no copay and no coinsurance for primary care visits, preventive services, and home health care. Specialist visits require a $40 copay, while inpatient hospital stays have a daily copay of $375 for the first seven days and no copay thereafter. Emergency care is available with a $115 copay, which is waived if you are admitted to the hospital within 24 hours. This plan also includes valuable dental, vision, and hearing benefits, offering no copay and no coinsurance for most routine dental services and annual eye exams. Prescription hearing aids are covered with copays ranging from $699 to $999, and durable medical equipment is available with a 20% coinsurance and no copay. Skilled nursing facility care is covered with no copay for the first 20 days, followed by a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
HumanaChoice H5216-027 (PPO) covers inpatient acute hospital stays with no coinsurance and a $375 daily copay for days 1-7, followed by no copay for days 8 and beyond. Inpatient psychiatric stays are also covered with no coinsurance and a $375 daily copay for days 1-5 and no copay for days 6-90, though additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
HumanaChoice H5216-027 (PPO) covers outpatient services with no coinsurance, featuring copays ranging from $0 to $450 for outpatient hospital services and a $375 copay per stay for observation services. Ambulatory surgical center and blood services require no copays or coinsurance, while outpatient substance abuse sessions have a $35 copay.
Partial Hospitalization See details
HumanaChoice H5216-027 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to receive this benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-027 (PPO) covers Medicare-approved ground and air ambulance services with a $335.00 copay and no coinsurance, though prior authorization is required. Routine transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Emergency services are covered by HumanaChoice H5216-027 (PPO) for a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $115 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-027 (PPO) provides primary care physician services with no copay and no coinsurance, and specialist visits with a $40 copay and no coinsurance. Mental health, psychiatric, and therapy services require copays ranging from $25 to $35 with no coinsurance, while podiatry and routine chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by HumanaChoice H5216-027 (PPO) with no copay and no coinsurance for covered options like annual physical exams, kidney disease education, glaucoma screenings, and memory fitness. Sub-services that are not covered under this plan include health education, in-home safety assessments, personal emergency response systems, weight management programs, and nutritional or dietary benefits.
Hearing Services See details
HumanaChoice H5216-027 (PPO) hearing services are partially covered, featuring no coinsurance or deductibles, with a $40 copay for Medicare-covered exams and no copay for annual routine exams and fitting evaluations. Up to two prescription hearing aids are covered per year with a copay ranging from $699 to $999, though OTC hearing aids and inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by HumanaChoice H5216-027 (PPO) with no coinsurance and copays ranging from $0 to $40 for exams, while covered eyewear has no copay. One routine eye exam and one pair of contact lenses or eyeglasses are covered annually, but other eye exams, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by HumanaChoice H5216-027 (PPO), offering no copay and no coinsurance for most preventive and comprehensive services, though Medicare-covered dental services require a $40 copay and no coinsurance. While there is no maximum benefit limit for covered services, fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-027 (PPO) covers home infusion bundled services with no copay, although prior authorization is required. Medicare Part B drugs, including chemotherapy, radiation, and other drugs, have a coinsurance of 0% to 20%, while Medicare Part B insulin is covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by the HumanaChoice H5216-027 (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required for these covered services.
Medical Equipment See details
HumanaChoice H5216-027 (PPO) covers durable medical equipment and prosthetics with a 20% coinsurance and no copay. Diabetic supplies feature a 10% to 20% coinsurance with no copay, while diabetic therapeutic shoes or inserts require a $10 copay.
Diagnostic and Radiological Services See details
HumanaChoice H5216-027 (PPO) covers diagnostic and radiological services, requiring prior authorization for both categories. Lab services and diagnostic radiological services have no copay and no coinsurance, while diagnostic procedures range from no copay to a $120 copay with no coinsurance. Outpatient X-rays have no copay but require coinsurance, and therapeutic radiological services carry a minimum 20% coinsurance and a $40 copay.
Home Health Services See details
Home Health Services are covered under the HumanaChoice H5216-027 (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-027 (PPO) covers some cardiac rehabilitation services with no copay and no coinsurance, subject to prior authorization. However, standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-027 (PPO) covers Skilled Nursing Facility (SNF) care with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and additional days beyond the standard 100-day Medicare benefit period are not covered.
Other Services See details
HumanaChoice H5216-027 (PPO) offers partial coverage for other services, specifically covering acupuncture with a $40 copay, no coinsurance, and a limit of 20 treatments per year with prior authorization required. Supplemental benefits such as over-the-counter (OTC) items and meal benefits are not covered.
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