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HumanaChoice H5216-047 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-047 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-047 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-047 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in WA. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-047 (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 H5216-047 (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 H5216-047 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $85.00. 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 $300.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $400.00 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 $10000.00 (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 $10000.00 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 H5216-047 (PPO) plan has a $400 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you'll pay a $10 copay at preferred mail order pharmacies, and $20 at standard mail order pharmacies. For standard generic drugs, you'll pay a $47 copay. For preferred brand drugs, you'll pay 50% coinsurance. For non-preferred drugs, you'll pay 28% coinsurance. Once your total yearly drug costs reach $2000, you will enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-047 (PPO) plan offers coverage for a range of services, including inpatient and outpatient hospital care, with varying copays and coinsurance depending on the service. The plan also covers primary care, mental health, and specialist visits with copays, as well as preventive services like annual physical exams and some screenings with no copay. Additional benefits include coverage for ambulance services, emergency services, home health services, and skilled nursing facilities, each with their own cost-sharing structure. This plan provides hearing and vision services, including eye exams and eyewear with varying copays, and dental services, including oral exams and cleanings, with no copay. The plan covers services such as home infusion, dialysis, and medical equipment with coinsurance or copays. It also includes benefits like acupuncture and a meal benefit.
Inpatient Hospital See details
Inpatient Hospital benefits for HumanaChoice H5216-047 (PPO) include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with a copay of $380 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 are not covered.
Outpatient Services See details
Outpatient Services includes coverage for Outpatient Hospital Services with a $0-5 copay and 20% coinsurance, Observation Services with a $380 copay, and Ambulatory Surgical Center (ASC) Services with no copay and 20% coinsurance. Outpatient Substance Abuse Services have a 20% coinsurance and a $40 copay for individual and group sessions. Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-047 (PPO) plan, with a $60 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-047 (PPO) plan. Ground ambulance services have a $315 copay, while air ambulance services have a $1250 copay, with no coinsurance for either. 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 by HumanaChoice H5216-047 (PPO). Emergency Services have a $125 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation all have a $125 copay.
Primary Care See details
The HumanaChoice H5216-047 (PPO) plan covers primary care physician services with a $10 copay, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, and physician specialist services with a $45 copay. The plan also covers mental health specialty services and psychiatric services with no copay for individual and group sessions. Additionally, physical therapy and speech-language pathology services are covered with a $35 copay, additional telehealth benefits have a copay between $0 and $55, and opioid treatment program services have a 20% coinsurance and a $40 copay. However, routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The HumanaChoice H5216-047 (PPO) plan covers preventive services including an annual physical exam with no copay, as well as additional preventive services and kidney disease education services with a copay that is not specified. Glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit are also covered with no copay. Health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and other services are not covered.
Hearing Services See details
Hearing Services with the HumanaChoice H5216-047 (PPO) plan cover hearing exams for a $45 copay, but routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay between $0 and $45, while routine eye exams are not covered. Eyewear is covered with no copay, but contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-047 (PPO) plan covers 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. However, 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 with a $35 copay and 0-20% coinsurance, and other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for this benefit.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-047 (PPO) plan. This plan requires prior authorization and has a coinsurance of 20% for dialysis services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 15% coinsurance and Prosthetics/Medical Supplies with 15% coinsurance; Diabetic Equipment is covered, with cost sharing including coinsurance and copays for specific services. Diabetic Supplies have a 10-20% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, diagnostic procedures/tests with a copay between $0 and $55, and lab services with no copay. Radiological Services include coverage for diagnostic radiological services with a copay of at most $350, therapeutic radiological services with at most 20% coinsurance, and outpatient X-ray services with a $10 copay and at most 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-047 (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 not covered under the HumanaChoice H5216-047 (PPO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-047 (PPO) plan. For days 1-20, there is a $10 copay, for days 21-70, the copay is $214, and for days 71-100, there is no copay.
Other Services See details
The HumanaChoice H5216-047 (PPO) plan covers acupuncture with a $45 copay, and a meal benefit with no copay. Other services such as 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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