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HumanaChoice H5216-408 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-408 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-408 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-408 (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 2025.
It's important to know that HumanaChoice H5216-408 (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 H5216-408 (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 H5216-408 (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 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 $450.00 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 $14000.00 (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 $14000.00 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 H5216-408 (PPO) plan has a $450 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, in the initial coverage phase, you will pay no copay for preferred generic drugs at a standard pharmacy, while standard generic drugs have a $47 copay. Preferred brand drugs and non-preferred drugs have 45% and 27% coinsurance, respectively. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, and you will pay nothing for your Part D covered drugs.
Additional Benefits
The HumanaChoice H5216-408 (PPO) plan offers a range of benefits with varying costs. You'll have a $375 copay for inpatient hospital stays, with coverage for additional days. Outpatient services have copays ranging from $0 to $450, while primary care visits cost $5. The plan also covers preventive services, hearing, vision, and dental services, with specific copays and annual maximums. Emergency services have a $110 copay, and ambulance services have a $315 copay. Various other services like home health, medical equipment, and skilled nursing facilities are covered with different cost-sharing structures.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute with a $375 copay for days 1-6, and no copay for days 7-90, and Inpatient Hospital Psychiatric with a $375 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered with no copay for days 91-999, but Non-Medicare-covered stays and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital Services have a copay of $0-$450, Observation Services have a $375 copay, Ambulatory Surgical Center (ASC) Services have no copay, Individual and Group Sessions for Outpatient Substance Abuse have a copay between $45-$100, and Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-408 (PPO) plan, but requires prior authorization. The copay for this benefit is $80.
Ambulance and Transportation Services See details
Ambulance services, including ground and air ambulance, are covered by HumanaChoice H5216-408 (PPO) with a $315 copay, 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 under the HumanaChoice H5216-408 (PPO) plan. Emergency Services have a $110 copay and no coinsurance, while Urgently Needed Services have a $45 copay and no coinsurance. Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $110 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-408 (PPO) covers primary care physician services for a $5 copay, and chiropractic services for a $15 copay. The plan also covers occupational therapy services with a $25 copay, physician specialist services with a $50 copay, and physical therapy and speech-language pathology services for a $25 copay. Mental health and psychiatric services have a $45 copay for individual and group sessions, while opioid treatment program services have a minimum copay of $45 and a maximum copay of $100.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, annual physical exams with no copay, and additional services including fitness benefits with no copay. Kidney Disease Education Services, Glaucoma Screenings, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visits are also covered with no copay. Health Education, In-Home Safety Assessments, Personal Emergency Response Systems, Medical Nutrition Therapy, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefits, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing Services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Hearing exams have a $50 copay, while routine hearing exams and fitting/evaluation for hearing aids have no copay. Prescription hearing aids have a copay between $499 and $799, but inner ear, outer ear, and over the ear prescription hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
The HumanaChoice H5216-408 (PPO) plan covers vision services, including routine eye exams with a copay of $0 - $50 per visit. Eyewear is also covered with no copay, and a combined maximum benefit of $100 every year for both in-network and out-of-network services, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services are covered, with a maximum plan benefit of $3,000 per year for both in-network and out-of-network services. Medicare Dental Services have a $50 copay, and other services such as oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics, and oral and maxillofacial surgery have no copay. Fluoride treatments, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and coinsurance between 0% and 20%, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with coinsurance between 0% and 20%. Home Infusion bundled Services require prior authorization.
Dialysis Services See details
Dialysis Services are covered with prior authorization, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with a 12% coinsurance and Prosthetics/Medical Supplies with a 20% coinsurance. Diabetic Supplies have a coinsurance between 10-20% with no copay, while Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, lab services with no copay, and outpatient X-ray services with a $5 copay. Diagnostic Procedures/Tests have a copay between $0 and $120, while Diagnostic Radiological Services have a copay up to $325, and Therapeutic Radiological Services have a copay up to $50 and a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-408 (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
HumanaChoice H5216-408 (PPO) does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by HumanaChoice H5216-408 (PPO) with prior authorization required. There is no copay for days 1-20, and a $214 copay for days 21-100.
Other Services See details
Other Services includes acupuncture and a meal benefit, while over-the-counter items, Dual Eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered. Acupuncture has a $50 copay and the meal benefit has no copay.
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