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HumanaChoice H5216-428 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-428 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-428 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-428 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in OR, UT, WA. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-428 (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 H5216-428 (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 H5216-428 (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 $110.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $125.00 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 $10000.00 (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 $10000.00 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 H5216-428 (PPO) plan has a $125 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, in the initial coverage phase, preferred generic drugs have an $8 copay at preferred mail, and $20 at standard mail. Preferred brand drugs have 50% coinsurance, and non-preferred drugs have 31% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs.
Additional Benefits
The HumanaChoice H5216-428 (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have copays, while outpatient services have copays that vary. Emergency services have a $125 copay, and primary care visits have no copay. Preventive services, such as an annual physical exam, are covered with no copay, and some vision and dental services are covered with copays. Ambulance services, and some medical equipment, are covered with copays or coinsurance. Home health and skilled nursing facility services are covered, with some copays.
Inpatient Hospital See details
Inpatient Hospital benefits include acute and psychiatric care, with a copay of $495 for days 1-5 and no copay for days 6-90 for acute care, and a copay of $458 for days 1-5 and no copay for days 6-90 for psychiatric care. Additional days for Inpatient Hospital-Acute are covered with no copay, while non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services, with a copay between $0 and $495, observation services with a $495 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services have a copay between $40 and $45 for both individual and group sessions, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-428 (PPO) plan, but requires prior authorization. The copay for this benefit is $85.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by HumanaChoice H5216-428 (PPO). Ground Ambulance Services have a $315 copay, while Air Ambulance Services have a $1250 copay, and there is no coinsurance for either. Transportation Services are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the HumanaChoice H5216-428 (PPO) plan. Emergency Services have a $125 copay with no coinsurance, and Urgently Needed Services have a $55 copay with no coinsurance. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation all have a $125 copay with no coinsurance.
Primary Care See details
Primary Care Physician Services are covered with no copay. Chiropractic Services are covered with a $20 copay, but routine care is not covered. Occupational Therapy Services, Physical Therapy and Speech-Language Pathology Services, and Physician Specialist Services are covered with a $45 copay. Mental Health Specialty Services, Group Sessions for Mental Health Specialty Services, and Individual Sessions for Mental Health Specialty Services are covered with no copay. Other Health Care Professional services have a copay between $0 and $45. Psychiatric Services, Group Sessions for Psychiatric Services, and Individual Sessions for Psychiatric Services are covered with no copay. Additional Telehealth Benefits are covered with a copay between $0 and $55. Opioid Treatment Program Services are covered with a copay between $40 and $45.
Preventive Services See details
The HumanaChoice H5216-428 (PPO) plan covers preventive services including an annual physical exam with no copay, as well as kidney disease education services and other preventive services, such as glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit, all with no copay. Additional preventive services, such as health education, in-home safety assessments, and others are not covered.
Hearing Services See details
Hearing Services for HumanaChoice H5216-428 (PPO) include hearing exams with a $45 copay, but routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision services are covered under the HumanaChoice H5216-428 (PPO) plan, with eye exams costing between $0 and $45, and eyewear with no copay. Routine eye exams, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-428 (PPO) covers dental services, including Medicare Dental Services with a $45 copay, and other dental services with a $1,500 maximum benefit per year. Oral exams, dental x-rays, other diagnostic services, prophylaxis, other preventative services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with no copay. Fluoride treatment, maxillofacial prosthetics, implants, 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 coinsurance between 0% and 20%. Other Medicare Part B drugs also have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-428 (PPO) plan and require prior authorization. The coinsurance for these services is 20%.
Medical Equipment See details
Medical equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered under the HumanaChoice H5216-428 (PPO) plan. Durable Medical Equipment has a 10% coinsurance, and Prosthetic Devices and Medical Supplies both have a 10% coinsurance. For Diabetic Supplies, there is a 10-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services with a copay for Medicare-covered procedures/tests, and lab services with no copay. Therapeutic Radiological Services have a maximum copay of $25 and a minimum coinsurance of 20%, while Diagnostic Radiological Services have a maximum copay of $495. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-428 (PPO) plan with no copay and no coinsurance, although additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover any of the sub-services, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-428 (PPO) plan, but require prior authorization. For days 1-20, the copay is $10, for days 21-70 the copay is $214, and for days 71-100, there is no copay.
Other Services See details
The HumanaChoice H5216-428 (PPO) plan covers acupuncture with a $45 copay, and a meal benefit with 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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