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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 2025, 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 2025.
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 $9.00. 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 has a $500.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $225.00 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:
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Drug Coverage
The HumanaChoice H5216-037 (PPO) plan has a $225 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy. For preferred generic drugs, you will pay a $10 copay at preferred mail order pharmacies and a $20 copay at standard mail order pharmacies. For preferred brand drugs, you will pay 45% coinsurance, and for non-preferred drugs, you will pay 30% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-037 (PPO) plan offers a wide range of benefits with varying cost-sharing. You can expect copays for services like primary care ($5), specialist visits ($40), and emergency services ($125). The plan also provides coverage for inpatient hospital stays, outpatient services, and home health services, with specific copays or coinsurance depending on the service. Preventive services, such as annual physical exams, and routine hearing exams are available with no copay. The plan also covers hearing, vision, and dental services with varying copays, and offers additional benefits like ambulance services, diagnostic services, and medical equipment with copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a $299 copay for days 1-6, and no copay for days 7-90 for Inpatient Hospital-Acute; Inpatient Hospital Psychiatric has a $290 copay for days 1-6, and no copay for days 7-90. Additional Days for Inpatient Hospital-Acute has no copay for days 91-999, while Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, and Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $250, Observation Services with a $299 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse services with a copay between $40 and $55 for individual and group sessions, and Outpatient Blood Services with no copay. Prior authorization is required for these services.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. You will pay a $45 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-037 (PPO) plan, with no coinsurance for any services. Ground ambulance services have a $315 copay, while air ambulance services have a $1250 copay; however, transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the HumanaChoice H5216-037 (PPO) plan. Emergency Services have a $125 copay, and Urgently Needed Services have a $40 copay, while Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $125 copay. There is no coinsurance for any of these services.
Primary Care See details
Primary Care services include coverage for Primary Care Physician Services with a $5 copay. Chiropractic Services are covered with a $20 copay, while Occupational Therapy Services have a $40 copay. Physician Specialist Services have a $40 copay, and Physical Therapy and Speech-Language Pathology Services have a $40 copay. Additional Telehealth Benefits have a copay ranging from $0 to $40. Mental Health and Psychiatric services, and Opioid Treatment Program Services have a copay between $40 and $55. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
Preventive services, including annual physical exams, are covered. Annual physical exams have no copay, and many other preventive services have no copay.
Hearing Services See details
Hearing Exams are covered with a $40 copay, and Routine Hearing Exams are covered with no copay for one exam per year. Fitting/Evaluation for Hearing Aids has no copay. Prescription Hearing Aids (all types) are covered with a copay between $699 and $999 for two per year, but Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered. OTC Hearing Aids are not covered.
Vision Services See details
The HumanaChoice H5216-037 (PPO) plan covers vision services including eye exams with a copay of $0-$40, and eyewear with no copay. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a $40 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, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay, and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-037 (PPO) plan, but require prior authorization. The plan has a coinsurance of 20% for dialysis services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have a 10-20% coinsurance and no copay, and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures/tests, lab services, and radiological services, are covered. Diagnostic procedures/tests have a copay between $0 and $150, while lab services have no copay. Diagnostic radiological services have a copay up to $300, and therapeutic radiological services have a 20% coinsurance. Outpatient X-ray services have a $5 copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-037 (PPO) plan with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the HumanaChoice H5216-037 (PPO) plan, but no services are covered. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-037 (PPO) plan, with a copay of $10 for days 1-20 and $214 for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for acupuncture with a $40 copay and a limit of 20 treatments per year, and a meal benefit with no copay. Over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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