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HumanaChoice H5216-327 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-327 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-327 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-327 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in West Virginia. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-327 (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 H5216-327 (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 H5216-327 (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 $200.00 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 H5216-327 (PPO) plan has a $200 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, you can expect to pay a $10 copay for preferred generic drugs at a standard pharmacy, and 50% coinsurance for preferred brand drugs. Once your total drug costs reach $2000, you will enter the catastrophic coverage phase and pay nothing for your Part D covered drugs.
Additional Benefits
The HumanaChoice H5216-327 (PPO) plan offers a range of benefits with varying costs. For hospital stays, you'll pay a copay, with no copay for some days, and outpatient services have copays depending on the service. The plan also covers a variety of services such as primary care, preventive care, hearing, vision, and dental. Copays vary for these services, and some have no copay. The plan also offers additional benefits like ambulance services, emergency services, and home health services, with specific copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a copay of $380 for days 1-7 and 1-5, respectively, and no copay for days 8-90 for Inpatient Hospital-Acute and days 6-90 for Inpatient Hospital Psychiatric. Additional days for Inpatient Hospital-Acute have no copay for days 91-999, while Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and additional days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric 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 $380, while observation services have a $380 copay. Ambulatory surgical center services and outpatient blood services have no copay, and outpatient substance abuse services have a copay between $45 and $90 for individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-327 (PPO) plan and requires prior authorization. You will pay a $60 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-327 (PPO) plan, with a $315 copay for both Ground and Air Ambulance Services, 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. Emergency Services and Worldwide Emergency Coverage have a $110 copay, and Urgently Needed Services has a $45 copay. There is no coinsurance for any of these services.
Primary Care See details
The HumanaChoice H5216-327 (PPO) plan offers primary care services with no copay, chiropractic services with a $15 copay, and occupational therapy services with a copay between $20 and $35. The plan also covers physician specialist services with a $50 copay. Additionally, the plan offers mental health specialty services with a $45 copay for individual and group sessions, and psychiatric services with a $45 copay for individual and group sessions. Physical therapy and speech-language pathology services have a copay between $20 and $35, and telehealth services have a copay between $0 and $50. Finally, the plan covers opioid treatment program services with a copay between $45 and $90.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, annual physical exams with no copay, and additional preventive services, including Fitness Benefits, with no copay. Other services like health education, and home safety assessments are not covered.
Hearing Services See details
HumanaChoice H5216-327 (PPO) covers hearing exams for a $50 copay, and also covers routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are partially covered, with a copay between $399 and $699, and OTC hearing aids are covered up to $25 every three months.
Vision Services See details
The HumanaChoice H5216-327 (PPO) plan covers vision services including eye exams with a copay of $0-$50, 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 $50 copay, oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, and prosthodontics fixed, and oral and maxillofacial surgery with no copay. Fluoride treatment, prosthodontics removable, maxillofacial prosthetics, implant services, and orthodontics are not covered. There is a maximum plan benefit coverage of $1500 per year for both in and out-of-network services.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered. You may have a $35 copay for Medicare Part B Insulin Drugs and a coinsurance between 0% and 20% for all services, with prior authorization required.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-327 (PPO) plan, with a coinsurance of 20%. Prior authorization is required for this benefit.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment, Prosthetics/Medical Supplies, and Diabetic Equipment. Durable Medical Equipment has an 18% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have an 18% coinsurance, while Diabetic Supplies have a 10-20% coinsurance with no copay, and Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including all diagnostic services, diagnostic procedures/tests, and outpatient X-ray services, are covered with a copay of at most $100 for diagnostic procedures/tests, no copay for lab services and outpatient X-ray services, and at most $720 for diagnostic radiological services. Therapeutic radiological services are covered with a copay of at most $40 and 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-327 (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 not covered by the HumanaChoice H5216-327 (PPO) plan, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-327 (PPO) plan, but require prior authorization. There is no copay for days 1-20, and a $214 copay per day for days 21-100.
Other Services See details
Under "Other Services", acupuncture is covered with a $50 copay and a limit of 20 treatments per year. Over-the-counter items are covered, with a maximum benefit of $25 every three months, and the plan offers nicotine replacement therapy and Naloxone coverage. The plan also offers a meal benefit with no copay.
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