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Humana Value Choice H5216-261 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Humana Value Choice H5216-261 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Humana Value Choice H5216-261 (PPO) in 2026, please refer to our full plan details page.
Humana Value Choice H5216-261 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Denver and North Colorado. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Humana Value Choice H5216-261 (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 Choice H5216-261 (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 Choice H5216-261 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 has a $300.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $400.00 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 $8950.00 (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 $8950.00 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 Choice H5216-261 (PPO) prescription drug plan features an annual drug deductible of $400. For Tier 1 preferred generic drugs, members pay no copay for 1-month and 3-month supplies at standard pharmacies or through preferred mail order. Tier 2 generic drugs cost an $8 copay for a 1-month supply at standard pharmacies, while a 3-month supply has no copay when filled through preferred mail order. Tier 3 preferred brand drugs require a $47 copay for a 1-month supply, but you can save on a 3-month supply with a $94 copay via preferred mail order. Higher-tier medications require coinsurance rather than flat copays, with Tier 4 non-preferred drugs carrying a 46% coinsurance and Tier 5 specialty drugs requiring a 28% coinsurance.
Additional Benefits
The Humana Value Choice H5216-261 (PPO) plan offers robust core medical coverage with no copay for primary care physician visits and a $20 copay for specialists. For inpatient hospital stays, members pay a $325 daily copay for the first six days, with no copay required for days seven through 90. Emergency room visits have a $115 copay, which is waived if you are admitted, and routine preventive care is covered with no copay or coinsurance. This plan also includes valuable supplemental benefits, such as no copay for most preventive and comprehensive dental care up to a $2,500 annual limit. Routine eye and hearing exams feature no copay, with eyeglasses or contacts covered up to $250 annually and prescription hearing aids requiring a copay between $699 and $999. Home health services and laboratory tests are also available with no copay, while durable medical equipment and dialysis services require coinsurance.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Humana Value Choice H5216-261 (PPO) with no coinsurance, requiring a $325 daily copay for days 1 through 6 and no copay for days 7 through 90 for both acute and psychiatric stays. While unlimited additional acute care days are covered with no copay, additional psychiatric days, hospital upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Humana Value Choice H5216-261 (PPO) covers outpatient services with no coinsurance, offering ambulatory surgical center and outpatient blood services with no copay. Outpatient hospital and observation services have a copay of $0 to $325, while outpatient substance abuse sessions require a $25 to $35 copay, with prior authorization required for most services.
Partial Hospitalization See details
Partial hospitalization is covered by Humana Value Choice H5216-261 (PPO) with a $35.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Ambulance services are covered by Humana Value Choice H5216-261 (PPO) with a $335 copay for ground transport and a $630 copay for air transport, with no coinsurance required for either service. Routine transportation services, including trips to plan-approved or any health-related locations, are not covered.
Emergency Services See details
Humana Value Choice H5216-261 (PPO) covers emergency services with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $115 copay and no coinsurance.
Primary Care See details
Primary care services under the Humana Value Choice H5216-261 (PPO) feature no copay and no coinsurance for primary care physician visits, and a $20 copay with no coinsurance for specialists. Other benefits include physical therapy for a $35 copay, mental health services for a $25 copay, and telehealth for a $0 to $50 copay, all with no coinsurance. Some chiropractic services are covered, but routine and other chiropractic services are not covered.
Preventive Services See details
Humana Value Choice H5216-261 (PPO) covers preventive services, including annual physical exams, kidney disease education, and glaucoma screenings, with no copay and no coinsurance. Additional preventive benefits are partially covered, offering smoking cessation and memory fitness with no copay and no coinsurance, but excluding health education, PERS, in-home safety assessments, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, disease management, telemonitoring, remote access, home safety modifications, and counseling.
Hearing Services See details
Humana Value Choice H5216-261 (PPO) hearing services are partially covered, offering Medicare-covered exams for a $20 copay and no coinsurance, and routine exams and fitting evaluations for no copay and no coinsurance. Prescription hearing aids require a copay of $699 to $999 and no coinsurance, but OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Humana Value Choice H5216-261 (PPO) offers partially covered vision services with no coinsurance and copays ranging from $0 to $20, subject to prior authorization and no deductibles. One routine eye exam (no copay, up to $75) and eyewear like contact lenses or complete eyeglasses (no copay, up to $250 combined) are covered annually, while other eye exams, individual eyeglass lenses, individual frames, and upgrades are not covered.
Dental Services See details
Humana Value Choice H5216-261 (PPO) dental services are partially covered up to a combined $2,500 annual limit, with no copay and no coinsurance for most preventive and comprehensive care. Medicare-covered dental services have a $20 copay and no coinsurance, removable and fixed prosthodontics require a 30% coinsurance and no copay, while fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Humana Value Choice H5216-261 (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Covered Medicare Part B drugs, including chemotherapy, radiation, and insulin, carry no coinsurance to 20% coinsurance, with insulin also requiring a $35 copay.
Dialysis Services See details
Humana Value Choice H5216-261 (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
Humana Value Choice H5216-261 (PPO) covers durable medical equipment and medical supplies with a 15% coinsurance and no copay, and prosthetic devices with a 20% coinsurance and no copay. Diabetic supplies are covered with a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes and inserts require a $10 copay.
Diagnostic and Radiological Services See details
Humana Value Choice H5216-261 (PPO) covers diagnostic and radiological services with prior authorization, offering lab services, outpatient X-rays, and diagnostic radiological services with no copay. Diagnostic procedures and tests have a copay ranging from $0 to $100 with no coinsurance, while therapeutic radiological services require a minimum $40 copay and a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the Humana Value Choice H5216-261 (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are not covered under the Humana Value Choice H5216-261 (PPO) plan, as none of the sub-services, including intensive cardiac, pulmonary, and SET for PAD rehabilitation, are covered. Consequently, there is no copay or coinsurance for these services.
Skilled Nursing Facility (SNF) See details
Humana Value Choice H5216-261 (PPO) covers skilled nursing facility services with no coinsurance, offering no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. This benefit is partially covered because additional days beyond the Medicare limit are not covered, and prior authorization is required.
Other Services See details
Humana Value Choice H5216-261 (PPO) partially covers other services, offering acupuncture with a $20 copay and no coinsurance for up to 20 treatments per year, and meal benefits for chronic illnesses with no copay and no coinsurance. Over-the-counter (OTC) items are not covered under this plan, and prior authorization is required for the covered benefits.
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