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Humana Value Plus H5216-293 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Humana Value Plus H5216-293 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Humana Value Plus H5216-293 (PPO) in 2025, please refer to our full plan details page.
Humana Value Plus H5216-293 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in ID. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Humana Value Plus H5216-293 (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 Plus H5216-293 (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 Plus H5216-293 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $41.90. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $1.00. 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 $590.00 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 Humana Value Plus H5216-293 (PPO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590.00. In the initial coverage phase, after the deductible is met, you will pay 25% coinsurance for most drugs. Once your total drug costs reach $2000.00, you enter the next coverage phase.
Additional Benefits
The Humana Value Plus H5216-293 (PPO) plan offers a range of benefits, including inpatient hospital stays with varying copays depending on the length of stay. Outpatient services include coverage for a variety of services with copays and coinsurance, while emergency services have a $110 copay. This plan also covers primary care visits with a $10 copay, preventive services with no copay for an annual physical exam, and dental services with no copay. Additionally, the plan provides coverage for hearing exams and vision services, with differing copays based on the service.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you pay a copay of $728 for days 1-3, and no copay for days 4-90; for days 91-999 you have no copay. For Inpatient Hospital Psychiatric, you pay a copay of $678 for days 1-3, and no copay for days 4-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and Additional Days for Inpatient Hospital Psychiatric and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a 20% coinsurance and a copay between $0 and $50, while observation services have a $728 copay. Ambulatory surgical center services have no copay, and the coinsurance is 20%. Individual and group sessions for outpatient substance abuse have a 20% coinsurance. Outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Humana Value Plus H5216-293 (PPO) plan with an $80 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Humana Value Plus H5216-293 (PPO) plan. Ground ambulance services have a copay of $315, while air ambulance services have a copay of $1250; both have 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 under the Humana Value Plus H5216-293 (PPO) plan. Emergency Services and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation have a $110 copay, while Urgently Needed Services have a $45 copay; all have no coinsurance.
Primary Care See details
The Humana Value Plus H5216-293 (PPO) plan covers primary care physician services with a $10 copay, chiropractic services with 20% coinsurance (prior authorization required), occupational therapy services with 20% coinsurance (prior authorization required), physician specialist services with a $50 copay, mental health specialty services with no copay for individual and group sessions (prior authorization required), physical therapy and speech-language pathology services with 20% coinsurance (prior authorization required), additional telehealth benefits with a copay between $0 and $50, and opioid treatment program services with 20% coinsurance (prior authorization required). Podiatry services are not covered.
Preventive Services See details
The Humana Value Plus H5216-293 (PPO) plan covers preventive services, including an annual physical exam with no copay. The plan does not cover health education, in-home safety assessment, personal emergency response system (PERS), medical nutrition therapy (MNT), post discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefit, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, fitness benefit, enhanced disease management, telemonitoring services, remote access technologies, home and bathroom safety devices and modifications, and counseling services. Kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit all have no copay.
Hearing Services See details
Hearing Services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids. Hearing exams have a $50 copay, and routine hearing exams and fitting/evaluation for hearing aids have no copay. Prescription hearing aids (all types) have no copay for 2 visits every three years, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
The Humana Value Plus H5216-293 (PPO) plan covers vision services, including eye exams with a copay of $0-$50. Eyewear is also covered with no copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Humana Value Plus H5216-293 (PPO) covers dental services, including 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 with no copay. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered. There is a $1,500 annual maximum plan benefit for in-network and out-of-network services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, requiring prior authorization. The plan covers Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance and no copay.
Dialysis Services See details
Dialysis Services are covered under the Humana Value Plus H5216-293 (PPO) plan and require prior authorization, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 19% coinsurance, Prosthetics/Medical Supplies with a 20% coinsurance for medical supplies, and Diabetic Equipment with a 20% coinsurance for diabetic supplies. Medical equipment for use outside of the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures/tests, lab services, and radiological services. Diagnostic Procedures/Tests have a copay of up to $50 and a coinsurance of at most 20%, while Lab Services have no copay and a coinsurance of at most 20%. Diagnostic Radiological Services have a copay of up to $350 and a coinsurance of at most 20%, Therapeutic Radiological Services have a coinsurance of at most 20%, and Outpatient X-Ray Services have a $10 copay and a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the Humana Value Plus H5216-293 (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 the plan does not cover the sub-services: Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Humana Value Plus H5216-293 (PPO) plan, but require prior authorization. There is no copay for days 1-20 and days 91-100, but there is a $214 copay for days 21-90. Additional days beyond Medicare-covered SNF stays and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services includes acupuncture, which has a $50 copay per visit, and a meal benefit with no copay. 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, and Self-Directed Personal Assistance Services are not covered.
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