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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 $1.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $75.00 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, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, in the initial coverage phase, you can expect to pay $8 for preferred generic drugs at a standard pharmacy, and 50% coinsurance for preferred brand drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-428 (PPO) plan offers a range of benefits with varying costs. Hospital stays have a copay, while outpatient services have copays, and ambulance services have copays. The plan also covers primary care and specialist visits with no copay or a copay, along with vision and dental services. Preventive services have no copay.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $495 copay for days 1-5, and no copay for days 6-90, while for Inpatient Hospital Psychiatric you will pay a $458 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services are covered by the HumanaChoice H5216-428 (PPO) plan, including outpatient hospital services with a copay between $0 and $495, observation services with a $495 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a copay between $25 and $40 for individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-428 (PPO) plan, with an $85 copay, and requires prior authorization.
Ambulance and Transportation Services See details
Ambulance services are covered by HumanaChoice H5216-428 (PPO), with a $315 copay for ground ambulance services and a $1250 copay for air ambulance services, and no coinsurance. Transportation services to health-related locations 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 and no coinsurance, while Urgently Needed Services have a $55 copay and no coinsurance. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $125 copay.
Primary Care See details
The HumanaChoice H5216-428 (PPO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $45 copay, physician specialist services with a $45 copay, and mental health specialty services with no copay for individual and group sessions. This plan also covers physical therapy and speech-language pathology services with a $45 copay, additional telehealth benefits with a copay between $0 and $55, and opioid treatment program services with a copay between $25 and $40.
Preventive Services See details
The HumanaChoice H5216-428 (PPO) plan covers preventive services with no copay for the annual physical exam. Additional preventive services like Health Education, In-Home Safety Assessment, and others are not covered.
Hearing Services See details
HumanaChoice H5216-428 (PPO) covers hearing exams with a $45 copay, and routine hearing exams with no copay. Fitting/evaluation for hearing aids has no copay. Prescription hearing aids (all types) have a copay between $699 and $999. OTC hearing aids, and prescription hearing aids for the inner, outer, and over the ear are not covered.
Vision Services See details
The HumanaChoice H5216-428 (PPO) plan covers vision services, including eye exams with a copay of $0-$45. Eyewear is covered, with no copay for contact lenses and eyeglasses, and a combined maximum benefit of $150 every year, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-428 (PPO) plan covers Medicare Dental Services with a $45 copay. Other Dental Services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery, all with no copay, but fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered. The plan has a $1,500 maximum benefit coverage amount per year for both in-network and out-of-network services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-428 (PPO) plan, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment, Prosthetics/Medical Supplies, and Diabetic Equipment. Durable Medical Equipment has a 10% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies has a 10% coinsurance, and Diabetic Supplies have a 10-20% coinsurance with no copay, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by HumanaChoice H5216-428 (PPO), with prior authorization required. Diagnostic Procedures/Tests have a copay between $0 and $55, while Lab Services have no copay. Diagnostic Radiological Services have a copay up to $495, Therapeutic Radiological Services have a copay up to $25 and coinsurance up to 20%, and 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. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the HumanaChoice H5216-428 (PPO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-428 (PPO) plan, with a copay of $10 for days 1-20, $214 for days 21-70, and no copay for days 71-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include acupuncture with a $45 copay, and are limited to 20 treatments per year. However, over-the-counter items, meal benefits, 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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