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HumanaChoice H5216-281 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-281 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-281 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-281 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Clark and Nye Counties. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-281 (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 H5216-281 (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 H5216-281 (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 $250.00 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 HumanaChoice H5216-281 (PPO) plan has a $250 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you'll pay a $10 copay at preferred mail and standard pharmacies, and a $20 copay at standard mail pharmacies. For standard generic drugs, the copay is $47. For preferred brand drugs, you pay 32% coinsurance, and for non-preferred drugs, you pay 30% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for Part D covered drugs.
Additional Benefits
The HumanaChoice H5216-281 (PPO) plan offers a variety of health benefits with varying costs. Many services have no copay, including primary care visits, preventive services, routine hearing exams, eyewear, and outpatient x-rays. Other services have copays, such as inpatient hospital stays, specialist visits, and emergency services. This plan also covers vision and dental services, with copays for eye exams, dental services, and hearing exams. Additional benefits include home health services with no copay, and coverage for ambulance, and medical equipment. This plan has a $10 copay for days 1-20 for Skilled Nursing Facility (SNF) services, and a $214 copay for days 21-100.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For days 1-5, the copay is $295, and for days 6-90, there is no copay; additional days for Inpatient Hospital-Acute have no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered.
Outpatient Services See details
Outpatient services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient hospital services have a copay between $0 and $300, observation services have a $295 copay, ambulatory surgical center services have no copay, individual and group outpatient substance abuse sessions have a $20 copay, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-281 (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 by the HumanaChoice H5216-281 (PPO) plan, with prior authorization required for all ambulance services. Ground ambulance services have a $315 copay, and air ambulance services have a $630 copay, but transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $120 copay with no coinsurance, Urgently Needed Services have a $55 copay with no coinsurance, and Worldwide Emergency Services have a $120 copay with no coinsurance for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation.
Primary Care See details
The HumanaChoice H5216-281 (PPO) plan covers primary care physician services with no copay, and chiropractic services with a $20 copay. Occupational therapy services have a $25 copay, and physician specialist services have a $25 copay. Mental health specialty services, psychiatric services, and opioid treatment program services have a $20 copay for individual or group sessions. Physical therapy and speech-language pathology services have a $25 copay, and additional telehealth benefits range from no copay to a $55 copay.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services and annual physical exams with no copay. Additional preventive services, Kidney Disease Education Services, and Other Preventive Services are covered with no copay for services like Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit.
Hearing Services See details
The HumanaChoice H5216-281 (PPO) plan covers hearing exams for a $25 copay and routine hearing exams with no copay. Fitting/evaluation for hearing aids have no copay. Prescription hearing aids are covered, but the inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are covered with a maximum benefit of $50 every three months.
Vision Services See details
HumanaChoice H5216-281 (PPO) covers vision services, including eye exams with a copay between $0 and $25, and eyewear with no copay. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-281 (PPO) covers Medicare dental services with a $25 copay, oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services with 30% - 40% coinsurance, adjunctive general services, endodontics, periodontics, and prosthodontics, fixed with 30% - 40% coinsurance, and oral and maxillofacial surgery with no copay. Fluoride treatment, prosthodontics, removable, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the HumanaChoice H5216-281 (PPO) plan, with a $35 copay for Medicare Part B Insulin Drugs and coinsurance between 0% and 20% for the different types of drugs. Prior authorization is required for this benefit.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-281 (PPO) plan, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits are covered, including Durable Medical Equipment (DME) with a 25% coinsurance and Prosthetics/Medical Supplies with a 20% coinsurance. Diabetic Equipment is covered, with coinsurance ranging from 10% to 20% for Diabetic Supplies and a 20% coinsurance for Diabetic Therapeutic Shoes/Inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures and tests, are covered with a copay ranging from $0 to $85. Lab services have no copay, while diagnostic radiological services have a copay up to $190. Therapeutic radiological services have a 20% coinsurance and outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-281 (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-281 (PPO) does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for this benefit if it were covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-281 (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.
Other Services See details
The HumanaChoice H5216-281 (PPO) plan covers acupuncture with a $25 copay, up to 20 treatments per year, and requires prior authorization. This plan also offers an over-the-counter (OTC) items benefit with a maximum 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), 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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