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HumanaChoice H5216-182 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-182 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-182 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-182 (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 HumanaChoice H5216-182 (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 H5216-182 (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 H5216-182 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $15.00. 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 HumanaChoice H5216-182 (PPO) plan has no deductible for prescription drugs. In the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, preferred generic drugs have a $5 copay at preferred mail order, and standard generic drugs have a $47 copay. After your total drug costs reach $2000, you enter the catastrophic coverage phase. In this phase, you will pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The HumanaChoice H5216-182 (PPO) plan provides coverage for a wide range of healthcare services. The plan includes coverage for inpatient and outpatient hospital services, with varying copays depending on the specific service. You can expect to pay copays for services like primary care visits ($15), specialist visits ($55), emergency services ($125), and ambulance services ($315), with some services like preventive care and dental exams having no copay.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with a copay of $440 for days 1-6 (Acute) or 1-5 (Psychiatric), and no copay for days 7-90 (Acute and Psychiatric). Additional days for Inpatient Hospital-Acute have no copay, while Non-Medicare-covered stays and Upgrades for Inpatient Hospital-Acute, as well as Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, offered by HumanaChoice H5216-182 (PPO), includes coverage for all outpatient hospital services, with a copay between $0 and $440, and observation services with a $440 copay. The plan also covers Ambulatory Surgical Center (ASC) services and outpatient blood services with no copay, and outpatient substance abuse services with a copay between $55 and $95.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-182 (PPO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with a $315 copay for both ground and air ambulance services; however, transportation services to any health-related location are not covered. There is no coinsurance for any ambulance services.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are covered by HumanaChoice H5216-182 (PPO). Emergency Services have a $125 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $125 copay.
Primary Care See details
Under the HumanaChoice H5216-182 (PPO) plan, primary care physician services and chiropractic services have a $15 copay, while occupational therapy services have a $20-$40 copay. Physician specialist services have a $55 copay, and mental health and psychiatric services have a $55 copay for individual and group sessions. Physical therapy and speech-language pathology services have a $20-$40 copay, additional telehealth benefits have a $0-$55 copay, and opioid treatment program services have a $55-$95 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The HumanaChoice H5216-182 (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services are covered, with a copay, and other services like health education, home safety assessments, and several others are not covered. Kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following welcome visits are covered with no copay.
Hearing Services See details
Hearing Services are covered by the HumanaChoice H5216-182 (PPO) plan, but Routine Hearing Exams, Fitting/Evaluation for Hearing Aid, Prescription Hearing Aids (all types), Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, Prescription Hearing Aids - Over the Ear, and OTC Hearing Aids are not covered. Hearing Exams have a $55 copay.
Vision Services See details
The HumanaChoice H5216-182 (PPO) plan covers vision services, including eye exams with a copay of $0-$55 and eyewear with no copay, though eyeglass lenses, eyeglass frames, and upgrades are not covered. Routine eye exams, contact lenses, and eyeglasses (lenses and frames) are covered, with a limit of one routine eye exam, and one pair of contact lenses or eyeglasses (lenses and frames) every year.
Dental Services See details
The HumanaChoice H5216-182 (PPO) plan covers dental services, including oral exams with no copay, dental x-rays with no copay, other diagnostic dental services with no copay, prophylaxis (cleaning) with no copay, restorative services with no copay, adjunctive general services with no copay, endodontics with no copay, periodontics with no copay, prosthodontics (removable) with no copay and 30% coinsurance, prosthodontics (fixed) with no copay and 30% coinsurance, and oral and maxillofacial surgery with no copay. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered. There is a $3,000 maximum plan benefit coverage amount per year for both in-network and out-of-network services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and 0-20% coinsurance, while other services have a 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-182 (PPO) plan, but require prior authorization. The coinsurance for dialysis services is between 20% and 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, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 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 are covered by the HumanaChoice H5216-182 (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $100, while Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $720. Therapeutic Radiological Services have a maximum copay of $45 and a coinsurance of at most 20%, while Outpatient X-Ray Services have a $15 copay.
Home Health Services See details
Home Health Services are covered under the HumanaChoice H5216-182 (PPO) plan with no copay and no coinsurance. However, Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but none of the sub-services are covered. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-182 (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
Under "Other Services", HumanaChoice H5216-182 (PPO) covers acupuncture with a $55 copay, but it is limited to 20 treatments per year and requires prior authorization. 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, or Self-Directed Personal Assistance Services.
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