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HumanaChoice H5216-266 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-266 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-266 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-266 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Virginia. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-266 (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 H5216-266 (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 H5216-266 (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. Additionally, this plan comes with a Part B Premium reduction of $2.00. You must continue to pay paying your reduced 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 $350.00 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 HumanaChoice H5216-266 (PPO) plan has a $350 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and where you get your prescriptions filled. For example, you will pay a $5 copay for preferred generic drugs at a standard or preferred pharmacy, and a $20 copay if you use a standard mail order pharmacy. Once your total drug costs reach $2000, you will enter the catastrophic coverage phase where you pay nothing for your prescriptions.
Additional Benefits
The HumanaChoice H5216-266 (PPO) plan offers a wide range of benefits, including inpatient and outpatient hospital services, with varying copays. Emergency, primary care, preventive, hearing, vision, and dental services are also covered, with some services having no copay. Additional benefits include ambulance, home health, and skilled nursing facility services, along with medical equipment and diagnostic services. This plan also covers partial hospitalization, dialysis, and cardiac rehabilitation services, as well as other services like acupuncture, OTC items, and a meal benefit.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $399 copay for days 1-6, and no copay for days 7-90; for Inpatient Hospital Psychiatric, you will pay a $399 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with copays ranging from $0 to $450, and observation services with a $399 copay. Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services have no copay, while Outpatient Substance Abuse Services have copays between $45 and $100 for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-266 (PPO) plan, with a copay of $80. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including both ground and air ambulance services, each with a $315 copay and no coinsurance. 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 HumanaChoice H5216-266 (PPO) plan. Emergency Services have a $110 copay, while Urgently Needed Services have a $45 copay; both have no coinsurance. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $110 copay, with no coinsurance.
Primary Care See details
Under HumanaChoice H5216-266 (PPO), primary care physician services have no copay, chiropractic services have a $15 copay, and occupational therapy services have a $25 copay. Physician specialist services and physical therapy and speech-language pathology services have a $15 and $25 copay, respectively, while mental health and psychiatric individual and group sessions have a $45 copay. Other health care professional services have a copay between $0 and $15, and additional telehealth benefits have a copay between $0 and $45. Opioid treatment program services have a copay between $45 and $100. Podiatry services are not covered.
Preventive Services See details
Preventive Services include an annual physical exam with no copay, while additional preventive services, kidney disease education services, and other preventive services have varying copays. Some services like health education, in-home safety assessments, and others are not covered.
Hearing Services See details
The HumanaChoice H5216-266 (PPO) plan covers hearing exams for a $15 copay, routine hearing exams with no copay for 1 visit every year, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are partially covered, but not for inner ear, outer ear, or over the ear hearing aids, with a copay between $299 and $599 for all other types. OTC hearing aids are covered up to $50 every three months.
Vision Services See details
Vision services include eye exams with a copay of $0-$15 and eyewear with no copay. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services include coverage for Medicare Dental Services with a $15 copay, and other dental services with a $1,000 annual maximum benefit. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with no copay. 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. Medicare Part B Insulin Drugs have a $35 copay and 0-20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered, with a coinsurance of 20%. Prior authorization is required.
Medical Equipment See details
Medical equipment is covered under the HumanaChoice H5216-266 (PPO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a 20% coinsurance, and Medical Supplies have a 20% coinsurance. Diabetic Supplies have between 10% and 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 under the HumanaChoice H5216-266 (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $120, while Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $325, and Therapeutic Radiological Services have a maximum copay of $15 and a coinsurance of at least 20%. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-266 (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 covered, but none of the sub-services are covered. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the HumanaChoice H5216-266 (PPO) plan, but require prior authorization. There is no copay for days 1-20, and a $214 copay for days 21-100.
Other Services See details
Other Services include acupuncture with a $15 copay, Over-the-Counter (OTC) Items with a maximum benefit of $50 every three months, and a Meal Benefit with no copay; however, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), and other services are not covered.
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