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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 $50.00 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 used. For example, in the initial coverage phase, you will 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, including inpatient hospital stays with copays, outpatient services with varying copays, and no copays for primary care visits. The plan also covers preventive services like annual physical exams and kidney disease education with no copay, as well as hearing, vision, and dental services with copays or coinsurance. Additional benefits include ambulance services, emergency services, and home health services with no copays, as well as coverage for medical equipment, diagnostic services, and skilled nursing facilities.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute with a $495 copay for days 1-5, and no copay for days 6-90, and Inpatient Hospital Psychiatric with a $458 copay for days 1-5 and no copay for days 6-90. Additional Days for Inpatient Hospital-Acute are covered with no copay for days 91-999. 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, including all outpatient hospital services, are covered by HumanaChoice H5216-428 (PPO). Outpatient hospital services have a copay between $0 and $495, and observation services have a $495 copay, while Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services have no copay. Outpatient substance abuse services have a copay between $25 and $40.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-428 (PPO) plan with a $85 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by HumanaChoice H5216-428 (PPO). Ground ambulance services have a $315 copay, and air ambulance services have a $1250 copay, while 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 by the HumanaChoice H5216-428 (PPO) plan. Emergency Services have a $125 copay, and Urgently Needed Services have a $55 copay; there is no coinsurance for either. 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 have a $20 copay, while occupational therapy services have a $45 copay. The plan also covers physician specialist services with a $45 copay, and mental health specialty services with no copay for individual and group sessions. Physical therapy and speech-language pathology services have a $45 copay, and additional telehealth benefits have a copay between $0 and $55. Opioid treatment program services have a copay between $25 and $40.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services, annual physical exams with no copay, and kidney disease education services with no copay. Other preventive services such as glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following welcome visits have no copay. Additional preventive services such as health education, in-home safety assessments, and others are not covered.
Hearing Services See details
Hearing Services are covered by HumanaChoice H5216-428 (PPO), including hearing exams with a $45 copay, but routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids (all types, inner ear, outer ear, and over the ear), and OTC hearing aids are not covered.
Vision Services See details
Vision services are covered, with a copay of $0-$45 for eye exams and no copay for eyewear. Routine eye exams and all eyewear benefits are not covered.
Dental Services See details
Dental services include coverage for Medicare dental services with a $45 copay, and other dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and other preventive dental services, all with no copay. Restorative services and prosthodontics (fixed and removable) are covered with no copay and a 30-40% coinsurance, while fluoride treatment, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the HumanaChoice H5216-428 (PPO) plan. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-428 (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 10% coinsurance and Prosthetic Devices, Medical Supplies, and Diabetic Equipment. Diabetic Supplies have a 10-20% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures and tests with a copay between $0 and $55, and lab services with no copay. Radiological services are covered, including diagnostic radiological services with a copay up to $495, therapeutic radiological services with a copay up to $25 and a coinsurance of at least 20%, and outpatient X-Ray services with 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 covered by HumanaChoice H5216-428 (PPO), but not covered in practice. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or 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 and non-Medicare-covered SNF days are not covered.
Other Services See details
The HumanaChoice H5216-428 (PPO) plan covers acupuncture with a $45 copay and meal benefits with no copay. Over-the-counter items, Dual Eligible SNPs, 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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