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Humana Value Choice H5216-318 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Humana Value Choice H5216-318 (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 H5216-318 (PPO) in 2026, please refer to our full plan details page.
Humana Value Choice H5216-318 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select counties in MO/IL/KS. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Humana Value Choice H5216-318 (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 H5216-318 (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 H5216-318 (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 has a $350.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $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 $6200.00 (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 $6200.00 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 H5216-318 (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 budget-friendly, costing a $10 copay for a 1-month supply at standard pharmacies and no copay for a 3-month supply filled via preferred mail order. For Tier 3 preferred brand drugs, copays start at $47 for a 1-month supply, with a slightly discounted $131 copay for a 3-month supply when using preferred mail order. Higher-tier medications require coinsurance, with Tier 4 non-preferred drugs carrying a 50% coinsurance for both 1-month and 3-month fills. Finally, Tier 5 specialty drugs require a 25% coinsurance for a 1-month supply across all standard pharmacy and mail order options.
Additional Benefits
The Humana Value Choice H5216-318 (PPO) offers robust medical coverage with no copay for primary care physician visits, routine preventive services, lab work, and outpatient X-rays. For specialized medical needs, members pay a $30 copay for specialist visits and physical therapy, while inpatient hospital stays require a daily copay of $375 for the first seven days. Emergency room visits have a $150 copay, which is waived if you are admitted within 24 hours, and urgent care services require a $65 copay. Supplemental care is a key feature of this plan, offering no copay for routine vision exams, eyeglasses, routine hearing exams, and home health services. Dental services are covered up to a $3,500 annual limit with no copay for most preventive and restorative procedures, while durable medical equipment and dialysis require a 20% coinsurance. Additionally, skilled nursing facility stays require a low $10 daily copay for the first 20 days, and over-the-counter items are provided with no copay.
Inpatient Hospital See details
Inpatient hospital benefits are partially covered by Humana Value Choice H5216-318 (PPO) with no coinsurance, requiring prior authorization and a daily copay of $375 for days 1 through 7 of acute stays and $334 for days 1 through 7 of psychiatric stays, with no copay for subsequent days. Hospital upgrades, non-Medicare-covered stays, and additional psychiatric days beyond 90 days are not covered.
Outpatient Services See details
Humana Value Choice H5216-318 (PPO) covers outpatient services with no coinsurance, including outpatient hospital services with a copay of $0 to $300 and observation services with a $375 copay per stay. There is no copay or coinsurance for ambulatory surgical center and outpatient blood services, while outpatient substance abuse sessions have a $35 copay and no coinsurance.
Partial Hospitalization See details
Humana Value Choice H5216-318 (PPO) covers partial hospitalization services with a $35 copay and no coinsurance. Prior authorization is required to access these covered services.
Ambulance and Transportation Services See details
Humana Value Choice H5216-318 (PPO) covers ground ambulance services with a $335 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required for both. Transportation services to plan-approved or any health-related locations are not covered under this plan.
Emergency Services See details
Humana Value Choice H5216-318 (PPO) emergency services are covered with a $150 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services are available with a $65 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $150 copay and no coinsurance.
Primary Care See details
Humana Value Choice H5216-318 (PPO) features no copay and no coinsurance for primary care physician services, while specialist visits, physical therapy, occupational therapy, and mental health sessions have a $30 copay and no coinsurance. Some chiropractic services are covered, but routine and other chiropractic services are not covered, and podiatry services are entirely not covered. Additional telehealth services range from no copay to a $65 copay with no coinsurance, and opioid treatment has a $35 copay with no coinsurance.
Preventive Services See details
Humana Value Choice H5216-318 (PPO) offers preventive services with no copay and no coinsurance, including annual physical exams, kidney disease education, glaucoma screenings, and a memory fitness benefit. However, additional preventive services are only partially covered, with excluded benefits including health education, in-home safety assessments, personal emergency response systems, and nutritional counseling.
Hearing Services See details
Humana Value Choice H5216-318 (PPO) covers hearing services, offering OTC hearing aids and routine hearing exams with no copay and no coinsurance, while Medicare-covered exams require a $30 copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $699 to $999, though inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
Humana Value Choice H5216-318 (PPO) partially covers vision services with no deductibles, no coinsurance, and no copays for routine eye exams, contact lenses, and eyeglasses (lenses and frames). Other eye exam services, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Humana Value Choice H5216-318 (PPO) dental services are partially covered up to a $3,500 annual limit, featuring no copay and no coinsurance for most preventive, restorative, endodontic, periodontic, and oral surgery services. Medicare-covered dental has a $30 copay and no coinsurance, prosthodontics require no copay and 30% coinsurance, while fluoride treatments, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Humana Value Choice H5216-318 (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy may apply. Associated Medicare Part B chemotherapy, radiation, and other drugs have no copay and coinsurance ranging from no coinsurance to 20%, while covered Part B insulin requires a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Humana Value Choice H5216-318 (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Humana Value Choice H5216-318 (PPO) covers durable medical equipment and prosthetic devices with a 20% coinsurance and no copay. Medical supplies require a 15% coinsurance, 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
Diagnostic and radiological services are covered by Humana Value Choice H5216-318 (PPO) with prior authorization required. Diagnostic procedures and tests have a 20% coinsurance and copays up to $65, while lab services and outpatient X-rays have no copay. All radiological services feature no coinsurance, with diagnostic radiology requiring no copay and therapeutic radiology requiring a copay starting at $30.
Home Health Services See details
Humana Value Choice H5216-318 (PPO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are provided under Humana Value Choice H5216-318 (PPO) with no coinsurance and copays ranging from $10 to $30, requiring prior authorization. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and Supervised Exercise Therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
Humana Value Choice H5216-318 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Humana Value Choice H5216-318 (PPO) provides partially covered other services, featuring acupuncture for a $30 copay and no coinsurance, alongside over-the-counter items and chronic illness meal benefits with no copay and no coinsurance. Specific sub-services including Other 1, Other 2, Other 3, and Dual Eligible SNPs with Highly Integrated Services are not covered under this plan.
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