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HumanaChoice H5216-426 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-426 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-426 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-426 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in WA. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-426 (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 H5216-426 (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 H5216-426 (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 does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $350.00 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 $11500.00 (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 $11500.00 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 H5216-426 (PPO) plan has a $350 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, for a preferred generic drug, you will pay a $12 copay at a preferred pharmacy or through preferred mail order, and a $20 copay at a standard pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-426 (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, but many outpatient services, including primary care, mental health, and vision services, have no copay. The plan also covers ambulance services with a copay, and offers coverage for dental, hearing, and home health services, with some services requiring prior authorization. Diagnostic and radiological services have copays and coinsurance, and medical equipment and supplies have coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits for HumanaChoice H5216-426 (PPO) include acute care with a $597 copay for days 1-4, and no copay for days 5-90, while inpatient psychiatric care has a $505 copay for days 1-4, and no copay for days 5-90. Additional days for inpatient hospital acute care have no copay, but non-Medicare-covered stays and upgrades are not covered, and additional days and non-Medicare-covered stays for inpatient psychiatric care are also not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $400, observation services with a $597 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with a copay between $40 and $50 for individual and group sessions. Outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-426 (PPO) plan with an $80 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with a $315 copay for ground ambulance services and a $1250 copay for air ambulance services. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Services, are covered under the HumanaChoice H5216-426 (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, Urgently Needed Services have a $45 copay, and there is no coinsurance for any of these services.
Primary Care See details
The HumanaChoice H5216-426 (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy with a $35 copay, and specialist services with a $50 copay. Mental health and psychiatric services, including individual and group sessions, have no copay, while physical therapy and speech-language pathology services have a $35 copay. Additional telehealth benefits have a copay between $0 and $50, and opioid treatment program services have a copay between $40 and $50. Podiatry services are not covered.
Preventive Services See details
The HumanaChoice H5216-426 (PPO) plan covers preventive services, including an annual physical exam with no copay. Kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit are covered with no copay. Other preventive services like health education, in-home safety assessments, and more are not covered.
Hearing Services See details
Hearing exams are covered with a $50 copay, and routine hearing exams and fitting/evaluation for hearing aids are covered with no copay. Prescription hearing aids are partially covered, with a copay between $699 and $999 for prescription hearing aids (all types), but not for inner ear, outer ear, or over the ear hearing aids. OTC hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a copay of $0-$50, and eyewear with no copay. Contact lenses and eyeglasses (lenses and frames) are covered with no copay, while eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-426 (PPO) plan covers dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics, removable, prosthodontics, fixed, and oral and maxillofacial surgery; some services require prior authorization. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics, fixed, and oral and maxillofacial surgery have no copay. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay with a coinsurance between 0-20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0-20%.
Dialysis Services See details
Dialysis Services are covered with a coinsurance of 20%. Prior authorization is required for this benefit.
Medical Equipment See details
Medical Equipment is covered by HumanaChoice H5216-426 (PPO), including Durable Medical Equipment (DME) with a 15% coinsurance, Prosthetic Devices with a 20% coinsurance, and Medical Supplies with a 20% coinsurance. Diabetic Supplies have a coinsurance between 10% and 20% and no copay, while Diabetic Therapeutic Shoes/Inserts have no copay. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including all diagnostic services, with a minimum copay of $0 and a maximum copay of $55 for procedures/tests, and no copay for lab services. Outpatient X-Ray Services have no copay, while Diagnostic Radiological Services have a maximum copay of $400, and Therapeutic Radiological Services have a coinsurance of at most 20% and a copay of at most $25.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-426 (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover any specific services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-426 (PPO) plan, but require prior authorization. There is no copay for days 1-20 and days 76-100, but there is a $214 copay for days 21-75.
Other Services See details
Other Services include acupuncture and a meal benefit. Acupuncture has a $50 copay per visit and is limited to 20 treatments per year, while the meal benefit has no copay. Over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, 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.
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