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Humana Value Plus H5216-117 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Humana Value Plus H5216-117 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Humana Value Plus H5216-117 (PPO) in 2025, please refer to our full plan details page.
Humana Value Plus H5216-117 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Pennsylvania. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Humana Value Plus H5216-117 (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 Humana Value Plus H5216-117 (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 Humana Value Plus H5216-117 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $28.70. 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 $130.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $590.00 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 Humana Value Plus H5216-117 (PPO) plan has a $590 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 example, you will pay a $20 copay for preferred generic drugs at a standard or mail-order pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for your Part D covered drugs.
Additional Benefits
The Humana Value Plus H5216-117 (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services, including hospital and substance abuse services, have coinsurance. Emergency services have a copay, and primary care visits have a $20 copay. Preventive services, hearing exams, and eye exams have no copay, while vision services cover eyewear with no copay and a yearly maximum. Dental services cover some services with no copay, while home health services and ambulance services have no copay. Additional benefits such as medical equipment and diagnostic services have coinsurance.
Inpatient Hospital See details
Inpatient Hospital coverage includes Acute and Psychiatric care. For Inpatient Hospital-Acute, you pay a $680 copay for days 1-3, and no copay for days 4-90; additional days have no copay. For Inpatient Hospital-Psychiatric, you pay a $675 copay for days 1-2, and no copay for days 3-90. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services includes coverage for Outpatient Hospital Services with no copay and 18% coinsurance, Observation Services with a $680 copay, Ambulatory Surgical Center (ASC) Services with no copay and 18% coinsurance, Outpatient Substance Abuse Services with 18% coinsurance, and Outpatient Blood Services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Humana Value Plus H5216-117 (PPO) plan, but requires prior authorization. You will pay 18% coinsurance for this benefit.
Ambulance and Transportation Services See details
The Humana Value Plus H5216-117 (PPO) plan covers ambulance services with no copay and 18% coinsurance for both ground and air ambulance services. 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. Emergency Services and Worldwide Emergency Coverage have a $110 copay, while Urgently Needed Services has a $45 copay; all have no coinsurance. Worldwide Urgent Coverage and Worldwide Emergency Transportation also have a $110 copay, and no coinsurance.
Primary Care See details
The Humana Value Plus H5216-117 (PPO) plan covers primary care physician services with a $20 copay, while chiropractic services are partially covered with 18% coinsurance, and routine care is not covered. Occupational therapy, physician specialist services, and physical therapy have 18% coinsurance, and mental health specialty services, psychiatric services, and other health care professional services are covered with an 18% coinsurance. Additional telehealth benefits have 18% coinsurance with a copay between $0 and $45, and opioid treatment program services are covered with 18% coinsurance. Podiatry services are not covered.
Preventive Services See details
The Humana Value Plus H5216-117 (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, including fitness benefits, are covered with a $0 copay.
Hearing Services See details
Hearing exams are covered with a coinsurance of at most 18% for routine hearing exams, and fitting/evaluation for hearing aids have no copay. Prescription hearing aids (all types) are covered with no copay, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, nor are OTC hearing aids.
Vision Services See details
The Humana Value Plus H5216-117 (PPO) plan covers vision services, including eye exams with no copay and 18% coinsurance, and eyewear with no copay and a combined maximum of $250 per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with 18% coinsurance, and other dental services with a maximum benefit of $2000 per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and other preventive dental services are covered with no copay. Fluoride treatment, endodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 18%, while Medicare Part B Chemotherapy/Radiation Drugs have a coinsurance between 0% and 20%. Other Medicare Part B Drugs have no copay, and a coinsurance between 0% and 18%.
Dialysis Services See details
Dialysis services are covered by the Humana Value Plus H5216-117 (PPO) plan, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 16% coinsurance, Prosthetic Devices with 18% coinsurance, Medical Supplies with 18% coinsurance, and Diabetic Equipment with varying copays and coinsurance depending on the service. Durable Medical Equipment for use outside the home is not covered. Diabetic Supplies have a 10% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with a copay of up to $45 and at least 18% coinsurance, Lab Services with no copay, Diagnostic Radiological Services with no copay and at least 18% coinsurance, Therapeutic Radiological Services with at least 18% coinsurance, and Outpatient X-Ray Services with a $20 copay and at least 18% coinsurance. Prior authorization is required for all services.
Home Health Services See details
Home Health Services are covered by the Humana Value Plus H5216-117 (PPO) plan with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Humana Value Plus H5216-117 (PPO) plan. Specifically, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Humana Value Plus H5216-117 (PPO) plan, but require prior authorization. There is no copay for days 1-20, and a $214 copay 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 acupuncture, which has an 18% coinsurance, and a meal benefit with no copay. This plan does not cover 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.
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