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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 2025, 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 2025.
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 $45.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $2.00. 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 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 $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 H5216-100 (PPO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, for a preferred generic drug, you will pay a $5 copay at a standard or preferred mail pharmacy, or a $20 copay at a standard mail pharmacy. Once your total drug costs reach $2,000, you will enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-100 (PPO) plan offers a range of benefits, including coverage for inpatient and outpatient services, with varying copays depending on the specific service. The plan also includes coverage for ambulance and emergency services, as well as primary care, preventive, hearing, vision, and dental services, each with its own set of copays and limitations. This plan also provides coverage for home health services, dialysis, medical equipment, diagnostic and radiological services, cardiac rehabilitation, and skilled nursing facilities, with some services requiring prior authorization and coinsurance.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, with a $265 copay for days 1-7, and no copay for days 8-90. Additional days for inpatient hospital acute have no copay, while non-Medicare covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient services, including outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient Hospital Services have a copay between $0 and $250, Observation Services have a $265 copay, Ambulatory Surgical Center (ASC) Services have no copay, Individual and Group Sessions for Outpatient Substance Abuse have a $35 copay, and Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-100 (PPO) plan, with a $35 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-100 (PPO) plan. Ground Ambulance Services have a $315 copay, while Air Ambulance Services have a 20% coinsurance, and transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Services, are covered by the HumanaChoice H5216-100 (PPO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $30 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $125 copay.
Primary Care See details
The HumanaChoice H5216-100 (PPO) plan covers primary care physician services with a $5 copay, chiropractic services with a $15 copay, and occupational therapy services with a $15 copay. Physician specialist services have a $35 copay, and mental health specialty services, psychiatric services, and opioid treatment program services have a $35 copay for individual and group sessions. Physical therapy and speech-language pathology services have a $15 copay, while additional telehealth benefits have a copay between $0 and $35. Podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, annual physical exams with no copay, and additional preventive services with a copay that varies by service. Other services like Health Education, In-Home Safety Assessment, and several others are not covered.
Hearing Services See details
Hearing exams are covered with a $35 copay, and routine hearing exams are covered with no copay for one visit every year. Fitting/evaluation for hearing aids are covered with no copay, and prescription hearing aids are covered, but not for inner ear or outer ear hearing aids. OTC hearing aids are covered up to $30 every three months.
Vision Services See details
The HumanaChoice H5216-100 (PPO) plan covers vision services including eye exams and eyewear. Eye exams have a copay of $0-$35, and routine eye exams have no copay; eyewear has no copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-100 (PPO) plan covers Medicare Dental Services with a $35 copay, Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), and Other Preventive Dental Services with no copay. Fluoride Treatment, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered. The plan has a maximum benefit of $1,000 per year for both in-network and out-of-network services. Restorative Services have a $25 copay, and Adjunctive General Services have 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, as well as Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-100 (PPO) plan and require prior authorization. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment includes Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance and requires authorization. Prosthetic Devices and Medical Supplies have a 20% coinsurance, while Diabetic Supplies have a 10-20% coinsurance with no copay, and Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures and tests with a copay between $0 and $75, and lab services with no copay. Outpatient X-ray services have a $5 copay, while diagnostic radiological services have a copay up to $200, and therapeutic radiological services have a coinsurance up to 20% and a copay up to $50.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-100 (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 covered, but not the sub-services of 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. Prior authorization is required, and there is a copay for covered services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered under the HumanaChoice H5216-100 (PPO) plan, but require prior authorization. For days 1-20, there is a $10 copay, and for days 21-100, there is a $214 copay. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The HumanaChoice H5216-100 (PPO) plan covers acupuncture with a $35 copay, over-the-counter items with a $30 maximum benefit every three months, and meal benefits with no copay. However, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and other services are not covered.
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