A non-government entity
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 2026, 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 2026.
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 $1.00. 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 $615.00 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 $9500.00 (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 $9500.00 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:
Sign up for HumanaChoice H5216-428 (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The HumanaChoice H5216-428 (PPO) Medicare plan features an annual prescription drug deductible of $615. For Tier 1 preferred generic drugs, members pay no copay for a 1-month or 3-month supply at standard pharmacies and through preferred mail order. Tier 2 generic drugs are also highly affordable, costing as little as a $5 copay for a 1-month supply and featuring no copay for a 3-month supply through preferred mail order. Tier 3 preferred brand drugs have a standard 1-month copay of $47 at both standard pharmacies and mail order services. For higher-tier prescriptions, cost-sharing transitions to coinsurance, with Tier 4 non-preferred drugs requiring a 50% coinsurance and Tier 5 specialty drugs requiring a 25% coinsurance. This structured pricing helps beneficiaries understand exactly what they will pay for their medications under this HumanaChoice PPO plan.
Additional Benefits
The HumanaChoice H5216-428 (PPO) plan offers robust healthcare coverage with no copay or coinsurance for primary care visits, home health services, and preventive care. For inpatient hospital stays, members pay a copay for the first five days ($495 for acute and $458 for psychiatric care) and no copay for additional days, with no coinsurance required. Emergency room visits carry a $130 copay, which is waived if admitted within 24 hours, while urgent care visits require a $50 copay. This plan also includes valuable dental, vision, and hearing benefits, featuring no copay for preventive dental services up to a $1,500 annual limit and no copay for routine eye and hearing exams. Specialist visits and Medicare-covered dental services require a $45 copay, while durable medical equipment and dialysis services require a 20% coinsurance with no copay. Additionally, members can access over-the-counter items with no copay, though routine transportation services are not covered under this plan.
Inpatient Hospital See details
HumanaChoice H5216-428 (PPO) covers inpatient acute hospital stays with no coinsurance, requiring a $495 copay for days 1 through 5 and no copay for days 6 and beyond, though upgrades and non-Medicare-covered stays are not covered. Inpatient psychiatric hospital stays are also covered with no coinsurance, featuring a $458 copay for days 1 through 5 and no copay for days 6 through 90, while additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice H5216-428 (PPO) outpatient services are covered with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Covered outpatient hospital, observation, and substance abuse services require prior authorization and have no coinsurance, with copays ranging from no copay up to $495 depending on the service.
Partial Hospitalization See details
Partial hospitalization services are covered by HumanaChoice H5216-428 (PPO) with a $35.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
HumanaChoice H5216-428 (PPO) covers ground ambulance services with a $335.00 copay and air ambulance services with a $1,250.00 copay, with no coinsurance required for either service. Although transportation services are listed as covered, they are not covered in practice because transportation to both plan-approved and any health-related locations is not covered.
Emergency Services See details
HumanaChoice H5216-428 (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $130 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-428 (PPO) provides primary care physician, psychiatric, and mental health specialty services with no copay and no coinsurance. Specialist visits, physical therapy, occupational therapy, and speech-language services are covered with a $45 copay and no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
HumanaChoice H5216-428 (PPO) offers partially covered preventive services with no copay and no coinsurance for annual physical exams, kidney disease education, memory fitness, and diabetes self-management. However, several supplemental benefits are not covered, including health education, in-home safety assessments, personal emergency response systems, and medical nutrition therapy.
Hearing Services See details
HumanaChoice H5216-428 (PPO) hearing services feature no copay and no coinsurance for routine annual exams, fitting evaluations, and OTC hearing aids, while Medicare-covered exams require a $45 copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay of $699 to $999 for up to two devices per year, though inner ear, outer ear, and over-the-ear types are not covered.
Vision Services See details
HumanaChoice H5216-428 (PPO) offers partially covered vision services with no deductible and no coinsurance, featuring a copay ranging from no copay to $45 for eye exams and no copay for covered eyewear. One routine eye exam (up to $75 annually) and one pair of contact lenses or eyeglasses (up to a combined $150 annually) are covered, while other eye exams, individual lenses, individual frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-428 (PPO) partially covers dental services up to a $1,500 annual limit, featuring Medicare-covered dental for a $45 copay and no coinsurance, and other covered preventive and comprehensive services with no copay and no coinsurance. Fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-428 (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs have no copay and a coinsurance of 0% to 20%, while Part B insulin drugs have a $35 copay and a coinsurance of 0% to 20%.
Dialysis Services See details
HumanaChoice H5216-428 (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required to receive coverage for these services.
Medical Equipment See details
Medical equipment is covered by HumanaChoice H5216-428 (PPO), with durable medical equipment, prosthetics, and medical supplies requiring a 20% coinsurance and no copay. Diabetic supplies are covered with a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes and inserts require a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by HumanaChoice H5216-428 (PPO) with prior authorization required. Lab services and diagnostic radiological services have no copay, diagnostic procedures have no coinsurance and a copay of $0 to $50, outpatient X-rays have no copay but require coinsurance, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home health services are covered under the HumanaChoice H5216-428 (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-428 (PPO) offers cardiac rehabilitation services with no coinsurance and prior authorization, though in practice, some services are covered while cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and carry a $10 copay.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-428 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 through 20, a $218 daily copay for days 21 through 70, and no copay for days 71 through 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the Medicare-covered 100 days are not covered.
Other Services See details
HumanaChoice H5216-428 (PPO) provides partial coverage for other services, featuring acupuncture with a $45 copay and no coinsurance for up to 20 treatments yearly, and over-the-counter items with no copay and no coinsurance. Meal benefits and other additional services are not covered under this plan.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved