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HumanaChoice H5216-039 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-039 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-039 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-039 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Northern Nevada Area. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-039 (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 H5216-039 (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 H5216-039 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 has a $1500.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
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 H5216-039 (PPO) plan has an enhanced alternative drug benefit. There is no deductible for prescription drugs. In the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, you may pay a $10 copay for preferred generic drugs at a standard or preferred mail pharmacy, while you will pay 50% coinsurance for preferred brand drugs. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-039 (PPO) plan offers a range of benefits, including inpatient hospital stays with a $395 copay for the first five days, and outpatient services with copays ranging from $0 to $300. You'll also have access to primary care, preventive services, hearing, vision, and dental coverage, often with no copay or a low copay. Additional benefits include ambulance services with copays, emergency and urgently needed services, and home health services with no copay. The plan also covers services such as home infusion, dialysis, and medical equipment, and offers coverage for acupuncture and over-the-counter items. However, some services like cardiac rehabilitation, certain vision and dental services, and additional days in a skilled nursing facility may not be covered.
Inpatient Hospital See details
Inpatient Hospital services, including acute and psychiatric care, are covered. For acute care, you will pay a $395 copay for days 1-5, and no copay for days 6-90; for psychiatric care, you will pay a $395 copay for days 1-5, and no copay for days 6-90. Additional days for inpatient hospital psychiatric are not covered, and non-Medicare-covered stays and upgrades for inpatient hospital acute are not covered.
Outpatient Services See details
Outpatient services include coverage for all outpatient hospital services, with a copay between $0 and $300, and observation services with a $395 copay. Ambulatory surgical center (ASC) services and outpatient blood services have no copay, while outpatient substance abuse services have a copay between $30 and $100 for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-039 (PPO) plan, but requires prior authorization. You will have a $55 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-039 (PPO) plan, with prior authorization required for all ambulance services. Ground Ambulance Services have a $315 copay, while Air Ambulance Services have a $1250 copay; 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 H5216-039 (PPO) plan. Emergency Services has a $125 copay, and Urgently Needed Services has a $50 copay, while all Worldwide Emergency Services have a $125 copay. There is no coinsurance for these services.
Primary Care See details
The HumanaChoice H5216-039 (PPO) plan covers Primary Care Physician Services with no copay, and Chiropractic Services with a $20 copay. Occupational Therapy Services have a $35 copay. Physician Specialist Services have a $35 copay. Mental Health Specialty Services, including Individual and Group Sessions, have a $30 copay. Physical Therapy and Speech-Language Pathology Services have a $35 copay. Additional Telehealth Benefits have a copay between $0 and $50. Opioid Treatment Program Services have a copay between $30 and $100. Podiatry Services are not covered.
Preventive Services See details
The HumanaChoice H5216-039 (PPO) plan covers preventive services, including an annual physical exam with no copay, and other preventive services with varying copays. Kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit are also covered with no copay. However, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and other services are not covered.
Hearing Services See details
HumanaChoice H5216-039 (PPO) covers Hearing Services, including hearing exams with a $35 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription Hearing Aids are partially covered, with Prescription Hearing Aids (all types) covered for 2 every year with a copay between $699 and $999, while Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered. OTC Hearing Aids are covered, with a maximum benefit of $50 every three months.
Vision Services See details
The HumanaChoice H5216-039 (PPO) plan covers vision services, including eye exams with a copay between $0 and $35, and eyewear with no copay, both of which require prior authorization. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-039 (PPO) covers dental services including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and other preventive dental services with no copay, and it covers restorative services, adjunctive general services, endodontics, periodontics, and oral and maxillofacial surgery with no copay. Prosthodontics (removable and fixed) have a 30% coinsurance, and fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered. The plan has a maximum benefit of $1500 per year for both in-network and out-of-network services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the HumanaChoice H5216-039 (PPO) plan, and prior authorization is required. Medicare Part B Insulin Drugs have a $35 copay, with coinsurance between 0-20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0-20%.
Dialysis Services See details
Dialysis Services are covered, with a coinsurance of 20%. Prior authorization is required.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment, Prosthetics/Medical Supplies, and Diabetic Equipment, is covered. Durable Medical Equipment has a 20% coinsurance, and Prosthetic Devices have a coinsurance of 20%. Diabetic Supplies have a 10-20% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
The HumanaChoice H5216-039 (PPO) plan covers diagnostic and radiological services, including diagnostic procedures/tests with a copay between $0 and $150, and lab services with no copay. Diagnostic radiological services have a copay up to $300, while therapeutic radiological services have a 20% coinsurance, and outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-039 (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
HumanaChoice H5216-039 (PPO) does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-039 (PPO) plan, but require prior authorization. For days 1-20, the copay is $10, and for days 21-100, the copay is $214. Additional and non-Medicare-covered SNF days are not covered.
Other Services See details
Other Services includes coverage for acupuncture with a $35 copay, over-the-counter (OTC) items with a $50 maximum benefit every three months, and a meal benefit with no copay. This plan does not cover 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, or Self-Directed Personal Assistance Services.
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