A non-government entity
HumanaChoice H5216-037 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-037 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-037 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-037 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Clark and Nye Counties. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-037 (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 H5216-037 (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 H5216-037 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $15.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $1.00. You must continue to pay paying your reduced 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 $8950.00 (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 $8950.00 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:
Sign up for HumanaChoice H5216-037 (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The HumanaChoice H5216-037 (PPO) Medicare prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generics and Tier 2 generics, beneficiaries pay no copay for one-month and three-month supplies filled at standard pharmacies or through preferred mail order. If using standard mail order, Tier 1 drugs have a $10 copay and Tier 2 drugs have a $20 copay for a one-month supply. Tier 3 preferred brand drugs carry a $47 copay for a one-month supply, though a three-month supply through preferred mail order offers a reduced copay of $94. For higher-tier medications, Tier 4 non-preferred drugs require a 45% coinsurance, while Tier 5 specialty drugs incur a 25% coinsurance for a one-month supply. This plan offers clear cost-saving paths, particularly when utilizing preferred mail order services for brand-name prescriptions.
Additional Benefits
The HumanaChoice H5216-037 (PPO) plan provides comprehensive medical coverage with many essential services available at no copay and no coinsurance. Members pay nothing for primary care visits, preventive care, home health services, and routine dental or vision exams. For other medical needs, specialist visits require a $30 copay, while inpatient hospital stays have a $275 daily copay for the first six days and no copay thereafter. Emergency care is accessible with a $130 copay, and urgent care visits require a $50 copay. For specialized needs, durable medical equipment and dialysis services are covered with a 20% coinsurance and no copay. Skilled nursing facility care is also covered, requiring a $10 daily copay for the first 20 days and a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
HumanaChoice H5216-037 (PPO) covers inpatient hospital services with no coinsurance, requiring a $275 daily copay for days 1 through 6 and no copay for days 7 through 90 for both acute and psychiatric stays. While unlimited additional acute care days are covered with no copay, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
HumanaChoice H5216-037 (PPO) covers outpatient services with no coinsurance, including outpatient hospital services with a $0 to $325 copay and observation services with a $275 copay per stay. Ambulatory surgical center and outpatient blood services are covered with no copay or coinsurance, while outpatient substance abuse sessions require a copay of $25 to $35.
Partial Hospitalization See details
HumanaChoice H5216-037 (PPO) covers partial hospitalization services with a $35 copay and no coinsurance. Prior authorization is required to receive this benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-037 (PPO) covers ground ambulance services with a $335 copay and air ambulance services with a $1,250 copay, both with no coinsurance, while transportation services are not covered. Prior authorization is required for all ambulance services.
Emergency Services See details
HumanaChoice H5216-037 (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services have a $50 copay with no coinsurance, and worldwide emergency, urgent, and transportation services are covered under a $130 copay with no coinsurance.
Primary Care See details
HumanaChoice H5216-037 (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits, physical therapy, and occupational therapy require a $30 copay and no coinsurance. Mental health and psychiatric sessions have a $25 copay with no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
HumanaChoice H5216-037 (PPO) covers key preventive services, such as annual physical exams, kidney disease education, and diabetes self-management training, with no copay and no coinsurance. While a memory fitness benefit is also covered with no copay and no coinsurance, several supplemental benefits like health education, in-home safety assessments, and nutritional therapy are not covered.
Hearing Services See details
Hearing services are covered by HumanaChoice H5216-037 (PPO), featuring a $30 copay and no coinsurance for Medicare-covered exams, alongside annual routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are partially covered with a copay of $699 to $999 and no coinsurance for up to two devices per year, while OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-037 (PPO) offers vision services with no deductible, no coinsurance, and copays ranging from $0 to $30, with prior authorization required. While routine eye exams, contact lenses, and eyeglasses are covered with no copay up to annual limits, the benefit is only partially covered as other eye exams, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by HumanaChoice H5216-037 (PPO), featuring a $30 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for preventive exams, cleanings, and X-rays. While many comprehensive dental services are covered, fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-037 (PPO) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. Associated Medicare Part B chemotherapy and other drugs have no copay and range from no coinsurance to 20% coinsurance, while Part B insulin requires a $35 copay and ranges from no coinsurance to 20% coinsurance.
Dialysis Services See details
HumanaChoice H5216-037 (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive this covered benefit.
Medical Equipment See details
HumanaChoice H5216-037 (PPO) covers durable medical equipment, prosthetics, and medical supplies with a 20% coinsurance and no copay. Diabetic supplies are covered with a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes or inserts require a $10 copay.
Diagnostic and Radiological Services See details
HumanaChoice H5216-037 (PPO) covers diagnostic and radiological services with no coinsurance for diagnostic services, no copay for lab services or outpatient X-rays, and prior authorization required. Diagnostic procedures and tests carry a copay of $0 to $150, diagnostic radiological services have a copay starting at $0, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
HumanaChoice H5216-037 (PPO) covers Home Health Services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered with no copay and no coinsurance under HumanaChoice H5216-037 (PPO) with prior authorization, though only some services are covered as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-037 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 copay for days 1 to 20 and a $218 copay for days 21 to 100. Prior authorization is required, a prior three-day inpatient hospital stay is not required, and additional days beyond the standard 100 days are not covered.
Other Services See details
HumanaChoice H5216-037 (PPO) provides partial coverage for other services, including acupuncture with a $30.00 copay and no coinsurance for up to 20 treatments per year, and a chronic illness meal benefit with no copay and no coinsurance. Both covered benefits require prior authorization, while over-the-counter (OTC) items are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved