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HumanaChoice H5216-425 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-425 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-425 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-425 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select counties 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 H5216-425 (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 H5216-425 (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 H5216-425 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $15.00. 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 does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $300.00 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 $13300.00 (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 $13300.00 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 H5216-425 (PPO) Medicare plan features an annual drug deductible of $300 and offers affordable options for prescription coverage. Tier 1 preferred generic drugs have no copay for one-month or three-month fills at standard pharmacies and through preferred mail order. Tier 2 generic drugs are also highly affordable, costing a $5 copay for a one-month supply at standard pharmacies and preferred mail order, and featuring no copay for a three-month supply via preferred mail order. For higher-tier medications, Tier 3 preferred brand drugs carry a $47 copay for a one-month supply, which can be reduced to $131 for a three-month supply using preferred mail order. Tier 4 non-preferred drugs require a 50% coinsurance for both one-month and three-month supplies across standard pharmacies and mail order options. Finally, Tier 5 specialty drugs incur a 29% coinsurance for a one-month supply through all available pharmacy and mail order services.
Additional Benefits
The HumanaChoice H5216-425 (PPO) Medicare Advantage plan offers comprehensive medical coverage with predictable out-of-pocket costs, featuring no copay and no coinsurance for primary care visits, preventive services, and home health care. Specialist visits, urgent care, and emergency services are covered with fixed copayments, while inpatient hospital stays require a daily copay for the first several days followed by no copay for the remainder of your stay. Additionally, this plan provides valuable supplemental benefits including routine dental care up to a $2,000 limit, routine vision exams, and routine hearing services with no copay or coinsurance. Members also enjoy no copay for select transportation services and over-the-counter items, while durable medical equipment and dialysis services are covered with a standard 20% coinsurance and no copay.
Inpatient Hospital See details
Inpatient hospital care is partially covered by HumanaChoice H5216-425 (PPO) with no coinsurance, requiring a $325 copay for days 1-7 of acute stays and days 1-5 of psychiatric stays, followed by no copay for remaining covered days. Non-Medicare-covered stays, room upgrades, and additional psychiatric days are not covered under this plan.
Outpatient Services See details
HumanaChoice H5216-425 (PPO) covers outpatient services with no coinsurance, although prior authorization is required for most care. Under this plan, there is no copay for ambulatory surgical center or blood services, while outpatient hospital services carry a $0 to $325 copay, observation services cost a $325 copay per stay, and outpatient substance abuse sessions require a $35 copay.
Partial Hospitalization See details
Partial hospitalization services are covered under the HumanaChoice H5216-425 (PPO) plan with a $35.00 copay and no coinsurance. Prior authorization is required to receive these covered services.
Ambulance and Transportation Services See details
HumanaChoice H5216-425 (PPO) covers ground and air ambulance services with a $335 copay and no coinsurance. Transportation services are partially covered, offering up to 24 one-way trips per year to plan-approved locations with no copay and no coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
HumanaChoice H5216-425 (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 covered with a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are available for a $115 copay and no coinsurance, with none of these services subject to a deductible.
Primary Care See details
HumanaChoice H5216-425 (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $40 copay and no coinsurance. Additional services like therapy, mental health, and telehealth carry copays ranging from $0 to $40 with no coinsurance, though chiropractic care is only partially covered because other chiropractic services are not covered.
Preventive Services See details
Preventive Services offered by HumanaChoice H5216-425 (PPO) are covered with no copay and no coinsurance for annual physical exams, kidney disease education, and select screenings. Additional supplemental benefits are only partially covered, offering a memory fitness benefit with no copay or coinsurance, while services like health education, weight management, and in-home safety assessments are not covered.
Hearing Services See details
HumanaChoice H5216-425 (PPO) covers routine hearing exams and fitting evaluations with no copay and no coinsurance, while Medicare-covered exams require a $40 copay and no coinsurance. Prescription hearing aids are partially covered with a $399 to $699 copay and no coinsurance for up to two devices per year, though inner ear, outer ear, and over the ear hearing aids are not covered. Unlimited over-the-counter (OTC) hearing aids are also covered with no copay and no coinsurance.
Vision Services See details
HumanaChoice H5216-425 (PPO) vision services are partially covered with no coinsurance, featuring no copay for annual routine eye exams and covered eyewear up to a $350 yearly limit, though other eye exams can carry a copay up to $40. This benefit does not cover other eye exam services, separate eyeglass lenses, separate eyeglass frames, or upgrades.
Dental Services See details
HumanaChoice H5216-425 (PPO) dental benefits are covered with no copay and no coinsurance up to a $2,000 annual maximum, while Medicare-covered dental services require a $40 copay and no coinsurance. The dental benefit is partially covered, as 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 H5216-425 (PPO) with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs have no coinsurance to 20% coinsurance, while covered insulin requires a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
HumanaChoice H5216-425 (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
HumanaChoice H5216-425 (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 and coinsurance.
Diagnostic and Radiological Services See details
HumanaChoice H5216-425 (PPO) covers diagnostic and radiological services with prior authorization, featuring no coinsurance for diagnostic services, no copay for lab work, and a $0 to $100 copay for diagnostic procedures. Radiological services include outpatient X-rays with no copay, diagnostic radiology starting at a $0 copay, and therapeutic radiology with a minimum $40 copay and 20% coinsurance.
Home Health Services See details
HumanaChoice H5216-425 (PPO) covers Home Health Services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered by HumanaChoice H5216-425 (PPO) with no coinsurance and prior authorization required. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and require a $10 copay.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-425 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and while a three-day prior hospital stay is not required, additional days beyond the standard Medicare-covered 100 days are not covered.
Other Services See details
HumanaChoice H5216-425 (PPO) partially covers other services, offering acupuncture with a $40 copay and no coinsurance, as well as over-the-counter items and meal benefits with no copay and no coinsurance. Specific benefits including Other 1, Other 2, Other 3, and Dual Eligible SNPs with Highly Integrated Services are not covered.
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