HumanaChoice H5216-152 (PPO)
HumanaChoice H5216-152 (PPO) H5216-152 Plan Details
HumanaChoice H5216-152 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-152
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
HumanaChoice H5216-152 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-152
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
HumanaChoice H5216-152 (PPO) H5216-152 Plan Details
HumanaChoice H5216-152 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-152
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
Virginia Counties Served
Henry
Botetourt
Montgomery
Franklin
Radford
Pittsylvania
Pulaski
Bedford
Bland
Martinsville City
Salem
Lynchburg City
Danville City
Loudoun
Clarke
Manassas City
Fauquier
Manassas Park City
Rappahannock
Winchester City
Falls Church City
Spotsylvania
Arlington
Accomack
King and Queen
Stafford
Alexandria City
Fredericksburg City
Hanover
Shenandoah
Gloucester
New Kent
Caroline
Richmond
Essex
Northumberland
Westmoreland
King George
Warren
Frederick
Page
Louisa
Richmond City
York
Amherst
Amelia
James City
Goochland
Poquoson City
Henrico
Cumberland
Powhatan
Chesterfield
Suffolk City
Southampton
Williamsburg City
Isle of Wight
Northampton
Portsmouth City
Chesapeake City
Virginia Beach City
Norfolk City
Newport News City
Floyd
Hampton City
Dinwiddie
Petersburg City
Prince George
Surry
Craig
Sussex
Colonial Heights City
Franklin City
Hopewell City
Appomattox
Roanoke
Campbell
Roanoke City
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $3400 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered Primary Care Office Visit $0 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $35 Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $35 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $460 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $460 |
| Urgent Care | Copayment for Urgent Care $65 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $135 |
| Emergency Room Visit | Copayment for Emergency Care $135 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $135 Copayment for Worldwide Emergency Transportation $135 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $300 Air Ambulance: Copayment for Air Ambulance Services $300 Prior Authorization Required for Air Ambulance Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $300 Copayment for Medicare Covered Ambulance Services - Air $300 |
Health Care Services and Medical Supplies
HumanaChoice H5216-152 (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $20 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Medicare Covered Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $20 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Supplies 10% to 20% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10 Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 10% to 20% Copayment for Medicare Covered Diabetic Therapeutic Shoes or Inserts $10 |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 20% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $85 Copayment for Medicare-covered Lab Services $0 to $65 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services $85 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$35 OP Diag Proc & Tests - SPC$65 OP Diag Proc & Tests - UCC$85 Sleep Study (Fac Based) - OPH$35 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_ Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $75 to $295 Copayment for Medicare-covered Therapeutic Radiological Services $35 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 to $95 Prior authorization required Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0 to $85 Copayment for Medicare Covered Lab Services $0 to $300 Copayment for Medicare Covered Diagnostic Radiological Services $75 to $295 Copayment for Medicare Covered Therapeutic Radiological Services $35 Coinsurance for Medicare Covered Therapeutic Radiological Services 20% Copayment for Medicare Covered Outpatient X-Ray Services $0 to $95 $85 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$35 OP Diag Proc & Tests - SPC$65 OP Diag Proc & Tests - UCC$85 Sleep Study (Fac Based) - OPH$35 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_ |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Medicare Covered Home Health Services: Copayment for Medicare Covered Home Health $0 |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $460 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital per Stay $460 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $35 Copayment for Medicare-covered Group Sessions $35 Out-of-Network: Medicare Covered Mental Health Services: Copayment for Medicare Covered Individual Sessions $35 Copayment for Medicare Covered Group Sessions $35 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $300 Prior Authorization Required for Outpatient Hospital Services $0 Diag Colonoscopy - OPH$85 Mental Health - OPH$300 Surgery Svcs - OPH$35 Wound Care - OPH_ Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $460 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $250 Prior Authorization Required for Ambulatory Surgical Center Services $0 Diag Colonoscopy - ASC$250 Surgery Svcs - ASC_ Prior authorization required Out-of-Network: Medicare Covered Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $300 Copayment for Medicare Covered Ambulatory Surgical Center Services $0 to $300 $0 Diag Colonoscopy - OPH$85 Mental Health - OPH$300 Surgery Svcs - OPH$35 Wound Care - OPH_ |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $35 to $85 Copayment for Medicare-covered Group Sessions $35 to $85 Prior Authorization Required for Outpatient Substance Abuse Services $85 OP Substance Abuse Care - OPH$35 OP Substance Abuse Care - SPC_ Prior authorization required Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $35 to $85 Copayment for Medicare Covered Group Sessions $35 to $85 $85 OP Substance Abuse Care - OPH$35 OP Substance Abuse Care - SPC_ |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
|
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $35 Prior Authorization Required for Podiatry Services Prior authorization required Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $35 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $196 per day for days 21 to 38 $0 per day for days 39 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $196 per day for days 21 to 38 $0 per day for days 39 to 100 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | 0% coinsurance for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. 0% coinsurance for panoramic film or diagnostic x-rays up to 1 every 5 years. 0% coinsurance for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. 0% coinsurance for emergency diagnostic exam up to 1 per year. 0% coinsurance for periodic oral exam, prophylaxis (cleaning) up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. 0% coinsurance for necessary anesthesia with covered service up to unlimited per year. $25 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $25 copayment for scaling for moderate inflammation up to 1 every 3 years. $25 copayment per tooth for amalgam and/or composite filling up to unlimited per year. $1,500 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.Out of Network0% coinsurance for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. 0% coinsurance for panoramic film or diagnostic x-rays up to 1 every 5 years. 0% coinsurance for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. 0% coinsurance for emergency diagnostic exam up to 1 per year. 0% coinsurance for periodic oral exam, prophylaxis (cleaning) up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. 0% coinsurance for necessary anesthesia with covered service up to unlimited per year. $25 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $25 copayment for scaling for moderate inflammation up to 1 every 3 years. $25 copayment per tooth for amalgam and/or composite filling up to unlimited per year. $1,500 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $35 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0
Members must use Humana's Medicare Insight Network, a national network of providers, which includes standard or PLUS providers. The allowance for the standard network is $50 less than the PLUS network. Out-of-Network: Medicare Covered Eye Exams Services: Copayment for Medicare Covered Eye Exams $35 Coinsurance for Medicare Covered Eye Exams 50% Copayment for Medicare Covered Eyewear $0 |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $35 Copayment for Routine Hearing Exams $0
Prior Authorization Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $699 to $999
Prior authorization required Out-of-Network: Medicare Covered Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $35 |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 Coinsurance for Medicare Covered Medicare-covered Preventive Services 50% |
