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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 2026, 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 2026.
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.
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 $615.00 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) prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generic drugs, you will pay no copay for a 1-month or 3-month supply at standard pharmacies and through preferred mail order. Tier 2 generic drugs are also highly affordable, costing as little as a $5 copay for a 1-month supply, or no copay for a 3-month supply when using preferred mail order. For Tier 3 preferred brand drugs, copays start at $47 for a 1-month supply, with savings available on 3-month supplies through preferred mail order. Tier 4 non-preferred drugs require a 39% coinsurance across standard pharmacies and mail order options. Specialty medications in Tier 5 carry a 25% coinsurance for a 1-month supply.
Additional Benefits
The HumanaChoice H5216-281 (PPO) plan offers robust coverage for essential medical services with predictable out-of-pocket costs and no coinsurance for many benefits. Members enjoy no copay for primary care visits, preventive services, and lab services, while specialist visits require a $30 copay. For hospital stays, inpatient care requires a $337 daily copay for the first five days and no copay for days six through 90, while emergency room visits carry a $130 copay that is waived if admitted. This plan also features strong supplemental benefits, including dental coverage up to a $2,500 annual limit with no copay for most preventive and restorative care. Routine hearing exams and fitting evaluations feature no copay, while eyewear is covered with no copay up to a $300 annual limit. Additionally, skilled nursing facility care requires a $10 daily copay for the first 20 days, and durable medical equipment is covered with no copay and a 20% coinsurance.
Inpatient Hospital See details
HumanaChoice H5216-281 (PPO) inpatient hospital benefits are partially covered with no coinsurance, requiring a $337 daily copay for days 1 through 5 and no copay for days 6 through 90. While unlimited additional acute care days are covered at no copay, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services under HumanaChoice H5216-281 (PPO) are covered with no coinsurance, featuring no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital services carry a copay ranging from no copay to $295, observation services require a $337 copay per stay, and outpatient substance abuse sessions have a copay of $25 to $35.
Partial Hospitalization See details
Partial hospitalization is covered under the HumanaChoice H5216-281 (PPO) plan with a $35.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by HumanaChoice H5216-281 (PPO), which features a $335 copay for ground ambulance and a $630 copay for air ambulance with no coinsurance for either service. While transportation is technically covered, some services are covered but transportation to plan-approved health-related locations and any health-related locations is not covered.
Emergency Services See details
HumanaChoice H5216-281 (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services are covered with a $50 copay and no coinsurance, while worldwide emergency, urgent care, and emergency transportation services are available with a $130 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-281 (PPO) covers primary care physician services and select telehealth benefits with no copay and no coinsurance. Other covered services, such as specialist visits ($30 copay), physical therapy ($25 copay), and mental health sessions ($25 copay), require no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
HumanaChoice H5216-281 (PPO) provides preventive services with no copay and no coinsurance, covering annual physical exams, kidney disease education, and a memory fitness benefit. Additional preventive benefits are only partially covered, excluding services such as health education, in-home safety assessments, weight management programs, and nutritional training.
Hearing Services See details
HumanaChoice H5216-281 (PPO) covers hearing services, offering routine hearing exams, fitting evaluations, and OTC hearing aids with no copay and no coinsurance. Medicare-covered exams require a $30 copay and no coinsurance, while prescription hearing aids are partially covered—excluding inner ear, outer ear, and over the ear types—with a copay of $699 to $999 and no coinsurance.
Vision Services See details
HumanaChoice H5216-281 (PPO) partially covers vision services with no coinsurance, offering eye exams with a $0 to $30 copay and eyewear with no copay up to a $300 annual limit. Covered benefits include one routine eye exam and one pair of contact lenses or eyeglasses (lenses and frames) per year, while other eye exam services, individual eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services under HumanaChoice H5216-281 (PPO) are partially covered up to a $2,500 annual maximum, with Medicare dental services requiring a $30 copay and no coinsurance. While most preventive and restorative services have no copay and no coinsurance, prosthodontics require no copay and 30% coinsurance, and fluoride treatment, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-281 (PPO) covers home infusion bundled services with no copay, although prior authorization is required. Medicare Part B drugs associated with these services, including chemotherapy and insulin, carry a coinsurance ranging from no coinsurance to 20%, with covered insulin having a $35 copay that does not apply to the plan deductible.
Dialysis Services See details
Dialysis Services are covered by HumanaChoice H5216-281 (PPO) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
HumanaChoice H5216-281 (PPO) covers medical equipment, including durable medical equipment (DME), prosthetics, and diabetic supplies, typically requiring prior authorization. DME, prosthetics, and medical supplies carry a 20% coinsurance with no copay, while diabetic supplies have a 10% to 20% coinsurance with no copay, and diabetic therapeutic shoes or inserts require a $10 copay.
Diagnostic and Radiological Services See details
HumanaChoice H5216-281 (PPO) covers diagnostic and radiological services, which require prior authorization. Members pay no copay and no coinsurance for lab services, a $0 to $85 copay with no coinsurance for diagnostic procedures, and a $0 copay for outpatient X-rays, while therapeutic radiological services require a copay and a minimum 20% coinsurance.
Home Health Services See details
Home health services are covered by HumanaChoice H5216-281 (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-281 (PPO) covers Cardiac Rehabilitation Services with no copay and no coinsurance, but only some services are covered in practice as standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation are not covered.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-281 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, though a prior three-day hospital stay is not necessary, and additional days beyond the standard Medicare benefit are not covered.
Other Services See details
HumanaChoice H5216-281 (PPO) covers acupuncture with a $30 copay and no coinsurance for up to 20 treatments per year, alongside over-the-counter items and chronic illness meal benefits with no copay and no coinsurance. Prior authorization is required for acupuncture and meal benefits, and certain other services are not covered.
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