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HumanaChoice H5216-363 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-363 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-363 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-363 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Virginia. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-363 (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 H5216-363 (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 H5216-363 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $19.50. 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 $13900.00 (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 $13900.00 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 H5216-363 (PPO) Medicare plan features an annual drug deductible of $615 before coverage begins. For Tier 1 preferred generics, there is no copay for a 1-month or 3-month supply at standard pharmacies and through preferred mail order. Tier 2 generic medications are also highly affordable, with a $5 copay for a 1-month supply and no copay for a 3-month supply when filled through preferred mail order. Tier 3 preferred brand drugs require a $47 copay for a 1-month supply, which drops to a $131 copay for a 3-month supply via preferred mail order. For higher-tier prescriptions, Tier 4 non-preferred drugs carry a 31% coinsurance, while Tier 5 specialty drugs require a 25% coinsurance. Knowing these copay and coinsurance structures helps you accurately budget for your prescription drug costs with this HumanaChoice PPO plan.
Additional Benefits
The HumanaChoice H5216-363 (PPO) plan provides strong coverage for essential medical services, offering no copay and no coinsurance for primary care and specialist visits. Emergency care is available with a $115 copay, while inpatient hospital stays require a $375 daily copay for the first several days before transitioning to no copay. Outpatient hospital services feature no coinsurance, with copays ranging up to $450 depending on the service. Supplemental benefits include no copay and no coinsurance for routine dental care up to a $2,000 annual limit, alongside no-copay vision and hearing exams. Beneficiaries receive a $250 yearly allowance for eyewear, while prescription hearing aids require copays between $199 and $499. Durable medical equipment and dialysis services are covered with a 20% coinsurance and no copay.
Inpatient Hospital See details
HumanaChoice H5216-363 (PPO) inpatient hospital care is partially covered with no coinsurance, though prior authorization is required. Medicare-covered acute stays require a $375 daily copay for days 1-7 (no copay for days 8 and beyond), while psychiatric stays require a $375 daily copay for days 1-5 (no copay for days 6-90). Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice H5216-363 (PPO) outpatient services are covered with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient hospital services require a copay of $0 to $450 ($375 per stay for observation), while outpatient substance abuse sessions have a $35 copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by HumanaChoice H5216-363 (PPO) with a $35.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-363 (PPO) covers Medicare-covered ground and air ambulance services with a $335 copay and no coinsurance, subject to prior authorization. Transportation services to plan-approved or any health-related locations are not covered under this plan.
Emergency Services See details
HumanaChoice H5216-363 (PPO) covers emergency services with a $115 copay (waived if admitted within 24 hours) and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with a $115 copay and no coinsurance, and none of these emergency costs count toward a plan deductible.
Primary Care See details
HumanaChoice H5216-363 (PPO) covers primary care and specialist services with no copay and no coinsurance, while physical, occupational, and speech therapies require a $25 copay and no coinsurance. Mental health, psychiatric, and opioid treatments carry a $35 copay and no coinsurance, whereas telehealth has a $0 to $40 copay and no coinsurance. Podiatry is not covered, and while some chiropractic services are covered, routine and other chiropractic services are not.
Preventive Services See details
HumanaChoice H5216-363 (PPO) preventive services are partially covered, offering an annual physical exam, memory fitness, kidney disease education, and select screenings with no copay and no coinsurance. However, several supplemental services are not covered under this plan, including health education, weight management programs, nutritional benefits, and in-home safety assessments.
Hearing Services See details
HumanaChoice H5216-363 (PPO) covers hearing exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are partially covered with a $199 to $499 copay and no coinsurance, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-363 (PPO) offers partially covered vision services with no copay, no coinsurance, and no deductible for covered benefits. Beneficiaries receive a $75 annual limit for one routine eye exam and a $250 yearly allowance for eyeglasses or contact lenses, though other eye exams, separate lenses or frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-363 (PPO) offers partially covered dental services with no copay and no coinsurance for covered services, up to a $2,000 annual maximum. While many preventive and comprehensive services are covered, fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-363 (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy and other drugs feature no copay and between no coinsurance and 20% coinsurance, while Part B insulin requires a $35 copay and between no coinsurance and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-363 (PPO) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
HumanaChoice H5216-363 (PPO) covers durable medical equipment, prosthetics, and medical supplies with a 20% coinsurance and no copay. Diabetic supplies are covered with a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes or inserts require a $10 copay.
Diagnostic and Radiological Services See details
HumanaChoice H5216-363 (PPO) covers diagnostic and radiological services, with prior authorization required for both. Diagnostic services feature no coinsurance, offering no copay for lab services and a copay of $0 to $120 for procedures and tests. Radiological services feature no copay for outpatient X-rays and diagnostic radiology, while therapeutic radiology requires a minimum 20% coinsurance and no minimum copay.
Home Health Services See details
Home Health Services are covered under the HumanaChoice H5216-363 (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by HumanaChoice H5216-363 (PPO) with no copay and no coinsurance, although prior authorization is required. While the benefit is technically covered, in practice only some services are covered, while standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by HumanaChoice H5216-363 (PPO), as additional days beyond the standard Medicare-covered limit are not covered. This benefit requires prior authorization but features no coinsurance, no copay for days 1 to 20, and a $218 copayment for days 21 to 100.
Other Services See details
HumanaChoice H5216-363 (PPO) partially covers other services, offering acupuncture and chronic illness meal benefits with no copay and no coinsurance, though prior authorization is required. Acupuncture is limited to 20 treatments per year, while Over-the-Counter (OTC) items are not covered.
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