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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 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 2026 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 has a $195.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $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 $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) prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generic drugs, you will pay no copay for a 1-month or 3-month supply at standard pharmacies and through preferred mail order. Tier 2 generic drugs cost as little as a $5 copay for a 1-month supply, or no copay for a 3-month supply when using preferred mail order. Tier 3 preferred brand drugs carry a $47 copay for a 1-month supply across standard pharmacies and mail order options. For higher-tier medications, the plan requires a 50% coinsurance for Tier 4 non-preferred drugs and a 25% coinsurance for Tier 5 specialty drugs. These structured copayments and coinsurance rates help you easily estimate your out-of-pocket prescription costs.
Additional Benefits
The HumanaChoice H5216-428 (PPO) plan offers robust coverage with no copay and no coinsurance for primary care visits, routine preventive services, home health care, and routine dental exams. For specialized care, beneficiaries pay a $45 copay with no coinsurance for specialist visits, Medicare-covered dental care, and Medicare-covered hearing exams. Inpatient hospital stays require a copay of $495 per day for days 1 to 5 of acute stays and $458 per day for days 1 to 5 of psychiatric stays, after which there is no copay. Emergency room visits carry a $130 copay, which is waived if admitted within 24 hours, while urgently needed services require a $50 copay. Durable medical equipment, prosthetics, and dialysis services are covered with a 20% coinsurance and no copay, while diagnostic lab services and outpatient x-rays are available with no copay. Additionally, the plan covers routine and comprehensive dental care up to a $1,500 annual limit and routine vision eyewear up to a $300 annual limit with no copay or coinsurance.
Inpatient Hospital See details
HumanaChoice H5216-428 (PPO) inpatient hospital benefits are partially covered with no coinsurance, requiring a $495 copay for days 1 to 5 of acute stays and a $458 copay for days 1 to 5 of psychiatric stays, with no copays for subsequent covered days. Non-Medicare-covered stays, hospital upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice H5216-428 (PPO) covers outpatient services with no coinsurance, including no copay and no coinsurance for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay of $0 to $495 (with a $495 copay per stay for observation services), while outpatient substance abuse sessions have a copay of $0 to $35.
Partial Hospitalization See details
HumanaChoice H5216-428 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to access this covered benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-428 (PPO) covers ambulance services with no coinsurance, requiring a $335 copay for ground ambulance services and a $1,250 copay for air ambulance services. While some transportation services are covered, transportation to plan-approved health-related locations and any other health-related locations is not covered.
Emergency Services See details
HumanaChoice H5216-428 (PPO) emergency services are covered with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $50 copay with no coinsurance, while worldwide emergency, urgent care, and emergency transportation are covered with a $130 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-428 (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits and therapy services require a $45 copay and no coinsurance. Mental health and psychiatric services feature no copay and no coinsurance, but podiatry and routine chiropractic care are not covered.
Preventive Services See details
HumanaChoice H5216-428 (PPO) provides partially covered preventive services with no copay and no coinsurance for covered benefits, which include annual physical exams, memory fitness, kidney disease education, and select screenings. However, several supplemental services are not covered under this plan, such health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and weight management programs.
Hearing Services See details
HumanaChoice H5216-428 (PPO) provides partially covered hearing services, featuring Medicare-covered exams for a $45 copay, and routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are covered with copays ranging from $699 to $999 and no coinsurance, but OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-428 (PPO) partially covers vision services with no deductible and no coinsurance, offering no copay for one routine eye exam and one pair of eyeglasses or contact lenses per year. However, other eye exam services, individual eyeglass lenses, eyeglass frames, and upgrades are not covered, and annual maximum benefit limits of $40 for exams and $300 for eyewear apply.
Dental Services See details
HumanaChoice H5216-428 (PPO) partially covers dental services, offering Medicare-covered dental care for a $45 copay and no coinsurance, alongside preventive and comprehensive dental services with no copay or coinsurance up to a $1,500 annual maximum. Fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered under this plan.
Home Infusion bundled Services See details
Home infusion bundled services are covered under HumanaChoice H5216-428 (PPO) with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs have no copay and 0% to 20% coinsurance, while Part B insulin requires a $35 copay and 0% to 20% coinsurance.
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
HumanaChoice H5216-428 (PPO) covers medical equipment, offering durable medical equipment (DME), prosthetics, and medical supplies with a 20% coinsurance and no copay. Diabetic supplies have a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes or inserts require a $10 copay.
Diagnostic and Radiological Services See details
HumanaChoice H5216-428 (PPO) covers diagnostic services with no coinsurance, offering lab services with no copay and diagnostic procedures with a $0 to $50 copay. Covered radiological services require prior authorization and include outpatient X-rays with no copay, diagnostic radiology with a minimum $0 copay, and therapeutic radiology with 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) covers some cardiac rehabilitation services with no coinsurance and a $10 copay, with prior authorization required. However, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) rehabilitation services are not covered.
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 1-20, a $218 daily copay for days 21-65, and no copay for days 66-100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the standard 100 days are not covered.
Other Services See details
HumanaChoice H5216-428 (PPO) partially covers other services, offering acupuncture with a $45 copay and no coinsurance for up to 20 treatments per year, though prior authorization is required. Over-the-counter (OTC) items and meal benefits are not covered under this plan.
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