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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 2026, 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 2026.
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.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan has a $250.00 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 $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 H5216-408 (PPO) plan features an annual prescription drug deductible of $450. For Tier 1 preferred generic and Tier 2 generic medications, there is no copay for either 1-month or 3-month supplies filled at standard pharmacies or through preferred mail order. Standard mail order options for these tiers require a $10 to $20 copay for a 1-month supply. Tier 3 preferred brand drugs require a $47 copay for a 1-month supply, with 3-month supplies costing $141 at standard pharmacies or a reduced $131 through preferred mail order. Tier 4 non-preferred drugs carry a 47% coinsurance for both 1-month and 3-month supplies across standard pharmacies and mail order. Tier 5 specialty drugs require a 27% coinsurance for a 1-month supply at standard pharmacies and mail order services.
Additional Benefits
The HumanaChoice H5216-408 (PPO) plan provides comprehensive coverage with no copay for primary care visits, routine preventive screenings, and home health care, while specialist visits require a $35 copay. For inpatient hospital stays, members pay a $375 copay per day for the first several days and no copay for subsequent days, with no coinsurance. Emergency room visits carry a $115 copay, which is waived if admitted, and urgent care is available for a $40 copay. The plan also features robust dental, vision, and hearing benefits, including no copay for most routine dental services up to a $3,000 annual maximum and no copay for routine annual eye exams. Routine hearing exams also have no copay, while prescription hearing aids require a copay ranging from $199 to $499. For dialysis and durable medical equipment, members can expect a 20% coinsurance with no copay.
Inpatient Hospital See details
HumanaChoice H5216-408 (PPO) covers inpatient hospital care with no coinsurance, requiring prior authorization and a $375 copayment for days 1 through 7 of acute stays and days 1 through 5 of psychiatric stays. No copayments apply to subsequent days, but room upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice H5216-408 (PPO) covers outpatient services with no coinsurance, including no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay ranging from $0 to $450, observation services carry a $375 copay per stay, and outpatient substance abuse sessions require a $35 copay. Prior authorization is required for most of these outpatient services.
Partial Hospitalization See details
Partial hospitalization services are covered by the HumanaChoice H5216-408 (PPO) plan with a $35.00 copay and no coinsurance. Prior authorization is required to receive these services.
Ambulance and Transportation Services See details
HumanaChoice H5216-408 (PPO) covers Medicare-approved ground and air ambulance services with a $335 copay per trip and no coinsurance, though prior authorization is required. Transportation services to plan-approved or any other health-related locations are not covered under this plan.
Emergency Services See details
HumanaChoice H5216-408 (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services are available with a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $115 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-408 (PPO) provides primary care physician services with no copay and no coinsurance, while specialist visits require a $35 copay and no coinsurance. Physical, occupational, and speech therapy services have a $25 copay with no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
HumanaChoice H5216-408 (PPO) preventive services are partially covered, offering annual physical exams, kidney disease education, memory fitness, and select screenings with no copay and no coinsurance. However, supplemental services such as health education, weight management, nutritional therapy, and in-home support are not covered.
Hearing Services See details
Hearing services are covered by HumanaChoice H5216-408 (PPO), which offers routine exams and fitting evaluations with no copay and no coinsurance, while Medicare-covered exams require a $35 copay. Prescription hearing aids are partially covered with a copay ranging from $199 to $499 and no coinsurance for up to two devices per year, but inner-ear, outer-ear, over-the-ear, and over-the-counter hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-408 (PPO) partially covers vision services with no deductible and no coinsurance, offering no copay for one annual routine eye exam (up to $75) and one annual pair of eyeglasses or contact lenses (up to $100). Copays range from $0 to $35 for other covered eye exams, while other eye exam services, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by HumanaChoice H5216-408 (PPO) up to a $3,000 annual maximum, with a $35 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for most other covered services. While many preventive and restorative treatments are included, fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by HumanaChoice H5216-408 (PPO) with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and insulin, have a coinsurance ranging from no coinsurance to 20%, with insulin capped at a $35 copay.
Dialysis Services See details
HumanaChoice H5216-408 (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
HumanaChoice H5216-408 (PPO) covers medical equipment, including durable medical equipment (DME) and prosthetics, with a 20% coinsurance and no copay. Diabetic supplies have a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes or inserts require a $10 copay and coinsurance, with prior authorization required for these benefits.
Diagnostic and Radiological Services See details
HumanaChoice H5216-408 (PPO) covers diagnostic and radiological services, with diagnostic tests and procedures requiring no coinsurance and a copay ranging from $0 to $120. Lab services feature no copay and no coinsurance, while outpatient X-rays have no copay but may carry coinsurance. Therapeutic radiological services require a minimum 20% coinsurance and a copay starting at $35, while diagnostic radiological services have a $0 minimum copay.
Home Health Services See details
Home health services are covered by the HumanaChoice H5216-408 (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by HumanaChoice H5216-408 (PPO) with no copay, no coinsurance, and required prior authorization. While some services are covered, specific sub-services including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation are not covered.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-408 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and additional days beyond the Medicare-covered 100-day limit are not covered.
Other Services See details
HumanaChoice H5216-408 (PPO) offers partial coverage for other services, featuring acupuncture with a $35 copay, no coinsurance, and a limit of 20 treatments per year with prior authorization. Over-the-counter (OTC) items, meal benefits, and other supplemental services are not covered.
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