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Humana Value Plus H5216-173 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Humana Value Plus H5216-173 (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 H5216-173 (PPO) in 2025, please refer to our full plan details page.
Humana Value Plus H5216-173 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Wisconsin. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Humana Value Plus H5216-173 (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 H5216-173 (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 H5216-173 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $39.00. 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 $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 $14000.00 (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 $14000.00 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 H5216-173 (PPO) plan has a $590 deductible for prescription drugs. After the deductible is met, you will pay the costs for your drugs based on the tier and pharmacy you use until your total drug costs reach $2000. Once you reach this amount, you enter the next coverage phase. If you qualify for the low-income subsidy, you will pay $39 per month for Part D coverage. After your yearly out-of-pocket drug costs reach $2000, you will pay nothing for Medicare Part D covered drugs, although you may still pay for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Humana Value Plus H5216-173 (PPO) plan offers a range of benefits, including coverage for inpatient and outpatient services, with varying copays and coinsurance amounts. Emergency, primary care, preventive, hearing, vision, and dental services are also covered, with specific cost-sharing structures for each. This plan provides coverage for ambulance services, home health, and skilled nursing facilities, with some services requiring prior authorization. Other services include home infusion, dialysis, medical equipment, and diagnostic and radiological services, with their own applicable copays and coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered. For Inpatient Hospital-Acute, there is a $1882 copay per admission or stay, and for Inpatient Hospital Psychiatric, there is a $1733 copay per admission or stay.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services and observation services have a 20% coinsurance, while outpatient hospital services have no copay, and observation services have a copay. Ambulatory Surgical Center (ASC) Services have a minimum and maximum coinsurance of 20%, with no copay. Outpatient substance abuse services including individual and group sessions, have a minimum and maximum coinsurance of 20%. Outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Humana Value Plus H5216-173 (PPO) plan, but requires prior authorization. You will pay 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Humana Value Plus H5216-173 (PPO) plan, with a $315 copay for ground ambulance services and 20% coinsurance for 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 by the Humana Value Plus H5216-173 (PPO) plan. Emergency Services has a $110 copay, and Urgently Needed Services has a 20% coinsurance with a maximum per visit amount of $45. Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $110 copay.
Primary Care See details
The Humana Value Plus H5216-173 (PPO) plan covers primary care, chiropractic, occupational therapy, physician specialist, mental health specialty, other health care professional, psychiatric, physical therapy and speech-language pathology, additional telehealth, and opioid treatment program services. Primary Care Physician Services, Chiropractic Services, Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services, and Additional Telehealth Benefits have a 20% coinsurance. Occupational Therapy Services, Individual Sessions for Mental Health Specialty Services, Group Sessions for Mental Health Specialty Services, Individual Sessions for Psychiatric Services, Group Sessions for Psychiatric Services, and Opioid Treatment Program Services have a coinsurance of 20%. Podiatry Services are not covered.
Preventive Services See details
The Humana Value Plus H5216-173 (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, EKG following Welcome Visit, and fitness benefits are also covered with no copay. However, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, 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 benefits, 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.
Hearing Services See details
Hearing exams are covered with a 20% coinsurance for routine hearing exams, and a $0 copay for Medicare-covered benefits and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered with a copay between $699 and $999, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
The Humana Value Plus H5216-173 (PPO) plan covers vision services including eye exams and eyewear. Eye exams have no copay and 20% coinsurance, while routine eye exams have no copay. Eyewear has no copay, with a combined maximum of $100 every year for both in-network and out-of-network services, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Humana Value Plus H5216-173 (PPO) plan covers dental services, with a $5,000 maximum benefit per year. Medicare Dental Services have a 20% coinsurance, while Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Other Preventive Dental Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, and Oral and Maxillofacial Surgery have no copay. Prosthodontics, removable, and Prosthodontics, fixed have a 30% coinsurance. Fluoride Treatment, Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and 0-20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is no copay and 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Humana Value Plus H5216-173 (PPO) plan and require prior authorization. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment is covered by the Humana Value Plus H5216-173 (PPO) plan, with a 20% coinsurance for Durable Medical Equipment, Prosthetic Devices, and Medical Supplies. Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Humana Value Plus H5216-173 (PPO) plan. Diagnostic Procedures/Tests have no copay and a coinsurance of at most 20%, while Lab Services have no copay and a coinsurance of at most 20%. Diagnostic Radiological Services have a copay of up to $350.00 and a coinsurance of at most 20%, Therapeutic Radiological Services have a coinsurance of at most 20%, and Outpatient X-Ray Services have a $65.00 copay and a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the Humana Value Plus H5216-173 (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 by the Humana Value Plus H5216-173 (PPO) plan. This includes Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Humana Value Plus H5216-173 (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include acupuncture, with a 20% coinsurance after prior authorization, and a meal benefit with no copay after prior authorization; however, 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. Acupuncture treatments are limited to 20 per year.
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