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Humana Full Access H5216-124 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Humana Full Access H5216-124 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Humana Full Access H5216-124 (PPO) in 2025, please refer to our full plan details page.
Humana Full Access H5216-124 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in West Virginia. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Humana Full Access H5216-124 (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 Full Access H5216-124 (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 Full Access H5216-124 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $126.00. 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 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 $10100.00 (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 $10100.00 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 Full Access H5216-124 (PPO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay varying copays or coinsurance depending on the drug tier and pharmacy used. For example, preferred generic drugs have a $15 copay at preferred mail pharmacies, while standard generic drugs have a $47 copay. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for your Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. If you qualify for the low-income subsidy, the plan's premium is reduced.
Additional Benefits
The Humana Full Access H5216-124 (PPO) plan offers a range of benefits with varying costs. This plan covers inpatient hospital stays with a $480 copay per admission. Emergency, primary care, and specialist services are also covered, with copays ranging from $10 to $125. Additional benefits include coverage for outpatient services, hearing and vision services, and dental services, which may include no copay. The plan also covers ambulance services, home health services, and medical equipment, with some services subject to copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, there is a $480 copay per admission or stay, and Additional Days are covered for Inpatient Hospital-Acute with no copay, but Non-Medicare-covered Stay and Upgrades are not covered.
Outpatient Services See details
Outpatient Services for the Humana Full Access H5216-124 (PPO) plan include coverage for all outpatient hospital services with a copay between $0 and $480, observation services with a $480 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a copay between $45 and $80, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Humana Full Access H5216-124 (PPO) plan with a $55 copay, and prior authorization is required.
Ambulance and Transportation Services See details
For the Humana Full Access H5216-124 (PPO) plan, Ambulance and Transportation Services are covered. Ground and Air Ambulance Services have a $315 copay, and there is no coinsurance; however, 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 Humana Full Access H5216-124 (PPO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $125 copay.
Primary Care See details
The Humana Full Access H5216-124 (PPO) plan covers primary care physician services with a $10 copay, chiropractic services with a $15 copay (prior authorization required), and occupational therapy services with a copay between $20 and $30 (prior authorization required). Physician specialist services have a $45 copay, while mental health specialty and psychiatric services have a $45 copay for individual and group sessions (prior authorization required). Physical therapy and speech-language pathology services have a copay between $20 and $30 (authorization required), and additional telehealth benefits have a copay between $0 and $55. Opioid Treatment Program Services have a copay between $45 and $80 (prior authorization required).
Preventive Services See details
Preventive services include an annual physical exam with no copay, and other services that may have a copay. Additional preventive services such as Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered. The plan also covers Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit with no copay.
Hearing Services See details
Hearing Services are partially covered by the Humana Full Access H5216-124 (PPO) plan, with a $45 copay for Hearing Exams, but Routine Hearing Exams, Fitting/Evaluation for Hearing Aids, Prescription Hearing Aids (all types, Inner Ear, Outer Ear, and Over the Ear), and OTC Hearing Aids are not covered.
Vision Services See details
The Humana Full Access H5216-124 (PPO) plan covers eye exams with a copay between $0 and $45, and routine eye exams have no copay. This plan also covers eyewear, including contact lenses and eyeglasses with no copay and a combined maximum benefit of $150 per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Humana Full Access H5216-124 (PPO) plan covers dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and other preventive dental services with no copay. Medicare Dental Services require a $45 copay. Restorative services require a $25 copay, and adjunctive general services have no copay. Fluoride treatment, endodontics, periodontics, prosthodontics, maxillofacial prosthetics, implant services, prosthodontics, fixed, oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, with a coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
The Humana Full Access H5216-124 (PPO) plan covers medical equipment, including Durable Medical Equipment (DME) with 20% coinsurance and Prosthetic Devices with 20% coinsurance. Diabetic Supplies have a 10-20% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including all diagnostic services, are covered and require prior authorization. Diagnostic Procedures/Tests have a copay between $0 and $90, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $500, Therapeutic Radiological Services have a copay of at most $30 and coinsurance of at most 20%, and Outpatient X-Ray Services have a $10 copay.
Home Health Services See details
Home Health Services are covered by the Humana Full Access H5216-124 (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit does require authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but specific services are not covered, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Humana Full Access H5216-124 (PPO) plan, but require prior authorization. For days 1-20, there is a $10 copay, and for days 21-100, the copay is $214; additional days beyond Medicare-covered are not covered.
Other Services See details
The Humana Full Access H5216-124 (PPO) plan covers acupuncture with a $45 copay, and a meal benefit with no copay. 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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