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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 2026, 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 2026.
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 $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 $400.00 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 $8500.00 (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 $8500.00 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) prescription drug plan features an annual drug deductible of $400. For Tier 1 preferred generic drugs, there is no copay for a 1-month or 3-month supply at standard pharmacies and through preferred mail order. Tier 2 generic medications cost a low $5 copay for a 1-month supply at standard pharmacies, and you will pay no copay for a 3-month supply filled through preferred mail order. Tier 3 preferred brand drugs have a $47 copay for a 1-month supply, which can be reduced to a $131 copay for a 3-month supply using preferred mail order. For higher-tier prescriptions, you will pay a 50% coinsurance for Tier 4 non-preferred drugs and a 28% coinsurance for Tier 5 specialty drugs. This structure helps you easily estimate your out-of-pocket costs when choosing the HumanaChoice H5216-327 (PPO) plan for your Medicare coverage.
Additional Benefits
The HumanaChoice H5216-327 (PPO) plan offers robust coverage for essential medical needs, featuring no copay or coinsurance for primary care visits, select telehealth services, and routine preventive care. For specialist visits, outpatient therapies, and emergency room care, members will pay flat copayments with no coinsurance. Inpatient hospital stays are also covered with no coinsurance, requiring daily copays for the first few days of care and no copay for subsequent days. This plan also includes valuable supplemental benefits, such as routine dental, vision, and hearing services, which feature no copays or coinsurance up to specified annual limits. Skilled nursing facility care is available with no copay for the first 20 days, while home health services are fully covered with no copay. For medical equipment, dialysis, and most Part B drugs, members can expect a coinsurance of up to 20 percent with no copayments.
Inpatient Hospital See details
HumanaChoice H5216-327 (PPO) partially covers inpatient hospital services with no coinsurance, though upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered. Acute care requires a $380 daily copay for days 1 to 7 and no copay for days 8 and beyond, while psychiatric care requires a $380 daily copay for days 1 to 5 and no copay for days 6 to 90.
Outpatient Services See details
Outpatient services are covered by HumanaChoice H5216-327 (PPO) with no coinsurance, featuring a $0 to $380 copay for outpatient hospital and observation services and a $35 copay for outpatient substance abuse sessions. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, though prior authorization is required.
Partial Hospitalization See details
HumanaChoice H5216-327 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to access this covered benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-327 (PPO) covers ground and air ambulance services with a $335 copay and no coinsurance, though prior authorization is required. While some transportation services are covered, trips to plan-approved or any health-related locations are not covered.
Emergency Services See details
HumanaChoice H5216-327 (PPO) covers emergency services with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $40 copay and no coinsurance, while worldwide emergency, urgent care, and emergency transportation are covered with a $115 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-327 (PPO) provides primary care physician services and select telehealth benefits with no copay and no coinsurance, while specialist visits require a $40 copay and no coinsurance. Physical, occupational, and mental health therapies have copays ranging from $20 to $40 with no coinsurance, though podiatry is not covered, and while some chiropractic services are covered, routine and other chiropractic services are not.
Preventive Services See details
HumanaChoice H5216-327 (PPO) offers preventive services with no copay and no coinsurance, covering annual physical exams, kidney disease education, fitness benefits, glaucoma screenings, diabetes self-management training, digital rectal exams, and post-welcome visit EKGs. However, the preventive benefit is only partially covered, as health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, chemotherapy-related wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation counseling, enhanced disease management, telemonitoring, remote access technologies, home/bathroom safety modifications, and counseling services are not covered.
Hearing Services See details
HumanaChoice H5216-327 (PPO) offers hearing services including Medicare-covered exams for a $40 copay and no coinsurance, alongside routine exams, fitting evaluations, and OTC hearing aids for no copay and no coinsurance. Prescription hearing aids are partially covered with a $399 to $699 copay and no coinsurance for up to two aids per year, though inner ear, outer ear, and over-the-ear models are not covered.
Vision Services See details
HumanaChoice H5216-327 (PPO) vision services are partially covered, offering one routine eye exam and eyewear like contact lenses or eyeglasses with no copay and no coinsurance up to a $350 annual maximum. Other eye exam services, individual eyeglass lenses, individual eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by HumanaChoice H5216-327 (PPO) up to a $1,500 annual maximum, featuring no copay and no coinsurance for most covered preventive and comprehensive services, though Medicare-covered dental services require a $40 copay and no coinsurance. Fluoride treatments, implants, orthodontics, maxillofacial prosthetics, and removable prosthodontics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-327 (PPO) covers Home Infusion bundled Services with no copay, although prior authorization is required. Covered Medicare Part B drugs, including chemotherapy and insulin, are subject to a coinsurance ranging from no coinsurance to 20%, with insulin drugs also requiring a $35 copay.
Dialysis Services See details
HumanaChoice H5216-327 (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
HumanaChoice H5216-327 (PPO) covers durable medical equipment, prosthetics, and medical supplies with a 20% coinsurance and no copay. Diabetic supplies are covered with no copay and a 10% to 20% coinsurance, while diabetic therapeutic shoes and inserts require a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by HumanaChoice H5216-327 (PPO), featuring no copay for lab services and outpatient X-rays, and a $0 to $100 copay with no coinsurance for diagnostic procedures and tests. Diagnostic radiological services have a minimum $0 copay, while therapeutic radiological services require a minimum $40 copay and 20% coinsurance, with prior authorization required for these services.
Home Health Services See details
Home Health Services are covered by HumanaChoice H5216-327 (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-327 (PPO) provides Cardiac Rehabilitation Services with no coinsurance and required prior authorization, although only some services are covered. Standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) rehabilitation services are not covered and require a $10 copay.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-327 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, while additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services covered by HumanaChoice H5216-327 (PPO) include acupuncture, which requires a $40 copay, no coinsurance, and prior authorization for up to 20 treatments per year. Over-the-counter items and a chronic illness meal benefit are also covered with no copay and no coinsurance, though prior authorization is required for the meals.
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