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Humana Full Access H5216-407 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Humana Full Access H5216-407 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Humana Full Access H5216-407 (PPO) in 2026, please refer to our full plan details page.
Humana Full Access H5216-407 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Missouri, Illinois. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Humana Full Access H5216-407 (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 Full Access H5216-407 (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 Full Access H5216-407 (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 $400.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $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 $5000.00 (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 $5000.00 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 Full Access H5216-407 (PPO) plan features an annual prescription drug deductible of $400. 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 medications cost a $10 copay for a 1-month supply at standard pharmacies, but you can pay no copay for a 3-month supply when using 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 through preferred mail order. For higher-tier prescriptions, Tier 4 non-preferred drugs carry a 50% coinsurance, while Tier 5 specialty drugs require a 28% coinsurance for a 1-month supply. This structured drug coverage helps beneficiaries manage their healthcare costs through affordable generic options and predictable copays.
Additional Benefits
The Humana Full Access H5216-407 (PPO) plan offers comprehensive medical coverage featuring no copay for primary care visits and preventive services, while specialist visits require a $30 copay. For hospital stays, members pay a daily copay of $375 for the first seven days of inpatient care and no copay for additional days. Emergency room visits carry a $130 copay, which is waived upon admission, while urgently needed services require a $50 copay. This plan also includes key supplemental benefits, such as dental coverage up to a $3,500 yearly limit and routine vision and hearing exams with no copays. Prescription hearing aids require copays ranging from $699 to $999, while durable medical equipment and dialysis services carry a 20% coinsurance. Additionally, home health care and over-the-counter items are covered with no copays or coinsurance.
Inpatient Hospital See details
Humana Full Access H5216-407 (PPO) covers inpatient acute hospital stays with no coinsurance, requiring a $375 daily copay for days 1 through 7 and no copay for days 8 and beyond. Inpatient psychiatric stays are also covered with no coinsurance, carrying a $334 daily copay for days 1 through 7 and no copay for days 8 through 90, though upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Humana Full Access H5216-407 (PPO) covers outpatient services with no coinsurance, including ambulatory surgical center and blood services which also require no copays. Outpatient hospital services require a copay of $0 to $300, observation services have a $375 copay per stay, and individual or group outpatient substance abuse sessions carry a $30 to $35 copay.
Partial Hospitalization See details
Humana Full Access H5216-407 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Humana Full Access H5216-407 (PPO), which offers ground ambulance with a $335 copay and no coinsurance, and air ambulance with a 20% coinsurance and no copay, though prior authorization is required. Transportation services are not covered under this plan, as trips to plan-approved or any other health-related locations are excluded.
Emergency Services See details
Humana Full Access H5216-407 (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $130 copay and no coinsurance.
Primary Care See details
Humana Full Access H5216-407 (PPO) covers primary care physician services with no copay and no coinsurance, and specialists, physical therapy, and mental health services with a $30 copay and no coinsurance. Telehealth services range from a $0 to $50 copay with no coinsurance, podiatry is not covered, and although some chiropractic services are covered with a $15 copay and no coinsurance, routine and other chiropractic services are not covered.
Preventive Services See details
Humana Full Access H5216-407 (PPO) covers preventive services, including annual physical exams, kidney disease education, select screenings, and a memory fitness benefit, with no copay and no coinsurance. This benefit is only partially covered because numerous supplemental services are not covered, including health education, weight management, in-home safety assessments, and nutritional or dietary therapy.
Hearing Services See details
Humana Full Access H5216-407 (PPO) covers hearing services with no coinsurance, offering routine hearing exams and fittings at no copay, Medicare-covered exams for a $30 copay, and OTC hearing aids at no copay. Prescription hearing aids are partially covered with a copay of $699 to $999 for up to two aids per year, though inner ear, outer ear, and over the ear models are not covered.
Vision Services See details
Humana Full Access H5216-407 (PPO) offers partially covered vision services with no deductible and no coinsurance, though prior authorization is required. Routine eye exams, contact lenses, and eyeglasses (lenses and frames) are covered with no copay under annual benefit maximums, while other eye exams, individual eyeglass lenses, individual frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by Humana Full Access H5216-407 (PPO) up to a yearly maximum of $3,500, offering no copay and no coinsurance for most preventive and comprehensive services, a $30 copay and no coinsurance for Medicare-covered dental, and a 30% coinsurance with no copay for prosthodontics. Fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Humana Full Access H5216-407 (PPO) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs have no copay and 0% to 20% coinsurance, while Medicare Part B insulin requires a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Humana Full Access H5216-407 (PPO) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Humana Full Access H5216-407 (PPO) covers durable medical equipment and prosthetic devices with a 20% coinsurance and no copay, and medical supplies with a 15% coinsurance and no copay. Diabetic supplies are covered with a 10% coinsurance and no copay, while diabetic therapeutic shoes or inserts require a $10 copay and no coinsurance.
Diagnostic and Radiological Services See details
Humana Full Access H5216-407 (PPO) covers diagnostic services with a minimum 20% coinsurance and copays ranging up to $50 for procedures, while lab services, diagnostic radiology, and outpatient X-rays require no copay. Therapeutic radiological services have a minimum copay of $30, and all radiological services feature no coinsurance, with prior authorization required for diagnostic and radiological services.
Home Health Services See details
Home Health Services are covered under the Humana Full Access H5216-407 (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Humana Full Access H5216-407 (PPO) does not cover Cardiac Rehabilitation Services, as none of the individual sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are covered.
Skilled Nursing Facility (SNF) See details
Humana Full Access H5216-407 (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 while a prior three-day hospital stay is not needed, additional days beyond the standard 100-day Medicare benefit are not covered.
Other Services See details
Humana Full Access H5216-407 (PPO) partially covers other services, offering acupuncture with a $30 copay and no coinsurance, alongside over-the-counter items and chronic illness meals with no copay and no coinsurance. Prior authorization is required for acupuncture and meal benefits, while other miscellaneous services are not covered.
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