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HumanaChoice H5216-100 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-100 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-100 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-100 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Southwest Virginia. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-100 (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 H5216-100 (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 H5216-100 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $33.00. 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 $9800.00 (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 $9800.00 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 H5216-100 (PPO) prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generic drugs, members pay no copay for a 1-month or 3-month supply at standard pharmacies and preferred mail-order services, while standard mail-order copays range from $10 to $30. Tier 2 generic drugs cost $5 for a 1-month supply at standard pharmacies and preferred mail order, and there is no copay for a 3-month supply when using preferred mail order. For Tier 3 preferred brand drugs, members pay a $47 copay for a 1-month supply, while a 3-month supply costs $141, or $131 through preferred mail order. Higher-tier medications require coinsurance, with Tier 4 non-preferred drugs requiring a 50% coinsurance for both 1-month and 3-month fills. Specialty drugs under Tier 5 carry a 25% coinsurance for a 1-month supply across all standard pharmacy and mail-order options.
Additional Benefits
The HumanaChoice H5216-100 (PPO) plan offers comprehensive medical coverage with no copay or coinsurance for primary care visits, preventive services, annual physicals, and home health care. For specialized care, members generally pay predictable copays, such as $35 for specialist visits and $130 for emergency room visits. Inpatient hospital stays feature a $265 daily copay for the first several days before transitioning to no copay, while outpatient hospital services range from no copay up to a $250 copay. This plan also includes valuable supplemental benefits, featuring no copay for routine vision eyewear, routine hearing exams, and preventive dental care, which is capped at a $1,000 annual limit. Major medical needs like durable medical equipment and dialysis require a 20% coinsurance with no copay. Additionally, members can take advantage of no copay for over-the-counter items, chronic illness meal benefits, and fitness programs.
Inpatient Hospital See details
HumanaChoice H5216-100 (PPO) covers inpatient hospital services with no coinsurance, featuring a $265 daily copay for days 1-7 of acute stays (no copay for days 8 and beyond) and a $265 daily copay for days 1-6 of psychiatric stays (no copay for days 7-90). This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice H5216-100 (PPO) outpatient services are covered with no coinsurance, featuring a $0 to $250 copay for outpatient hospital services and a $265 copay per stay for observation services. Ambulatory surgical center and outpatient blood services have no copay and no coinsurance, while outpatient substance abuse sessions require a $35 copay and no coinsurance.
Partial Hospitalization See details
HumanaChoice H5216-100 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-100 (PPO) covers ambulance services with a $335 copay for ground ambulance and a 20% coinsurance for air ambulance, with prior authorization required. Transportation services to plan-approved or any other health-related locations are not covered under this plan.
Emergency Services See details
HumanaChoice H5216-100 (PPO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $50 copay and no coinsurance, while worldwide emergency, urgent care, and emergency transportation services are covered with a $130 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-100 (PPO) offers primary care physician services with no copay and no coinsurance, while specialist visits and mental health services require a $35 copay and no coinsurance. Physical, occupational, and speech therapy services have a $15 copay with no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
HumanaChoice H5216-100 (PPO) covers preventive services, including annual physical exams, kidney disease education, and select screenings, with no copay and no coinsurance. While fitness benefits and in-home support are also covered with no copay and no coinsurance, other additional services such as health education, weight management, and counseling are not covered.
Hearing Services See details
Hearing services are covered by HumanaChoice H5216-100 (PPO) with a $35 copay and no coinsurance for Medicare-covered exams, while routine exams, fitting evaluations, and OTC hearing aids have no copay and no coinsurance. Prescription hearing aids are partially covered with a copay ranging from $399 to $699 and no coinsurance for up to two aids per year, but inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision Services are partially covered by HumanaChoice H5216-100 (PPO) with no deductible, no coinsurance, a $0 to $35 copay for eye exams, and no copay for eyewear. While routine eye exams and eyeglasses (lenses and frames) or contact lenses are covered up to annual benefit limits, other eye exam services, individual eyeglass lenses, individual eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-100 (PPO) dental benefits are partially covered up to a combined $1,000 annual limit, with no copay and no coinsurance for preventive care, a $25 copay and no coinsurance for restorative services, and a $35 copay and no coinsurance for Medicare-covered dental. Fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered under this plan.
Home Infusion bundled Services See details
HumanaChoice H5216-100 (PPO) covers home infusion bundled services with no copay, though prior authorization is required and step therapy may apply. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs have no copay and a 0% to 20% coinsurance, while Part B insulin drugs require a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the HumanaChoice H5216-100 (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
HumanaChoice H5216-100 (PPO) covers durable medical equipment, prosthetics, and medical supplies with a 20% coinsurance and no copay, subject to prior authorization. Covered diabetic supplies carry a 10% to 20% coinsurance with no copay, while diabetic therapeutic shoes and inserts require a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by HumanaChoice H5216-100 (PPO) with prior authorization required. Diagnostic tests feature no coinsurance and a copay of $0 to $75, lab and outpatient X-ray services have no copay, and therapeutic radiological services require a minimum 20% coinsurance and a $35 copay.
Home Health Services See details
HumanaChoice H5216-100 (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-100 (PPO) covers cardiac rehabilitation services with no copay and no coinsurance, though prior authorization is required. While some services are covered, specific sub-services such as intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) are not covered.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-100 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 copay for days 21 through 100. Prior authorization is required, a prior three-day inpatient hospital stay is not required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
HumanaChoice H5216-100 (PPO) covers acupuncture with a $35 copay and no coinsurance for up to 20 treatments per year, as well as over-the-counter items and chronic illness meal benefits with no copay and no coinsurance. Some services, including Dual Eligible SNPs with Highly Integrated Services, are not covered under this benefit.
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* 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.
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