HumanaChoice H5216-223 (PPO)
Available to residents of Rio Arriba County, NM for 2027. Contract H5216, plan 223, segment 0.
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- Rx cost-sharing for all pharmacies and tiers
- Other plans in Rio Arriba County
- Plan website
- Browse the HumanaChoice H5216-223 (PPO) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
Consolidated into another plan for 2027. CMS crosswalks 2026’s Humana Value Plus H5216-195 (PPO) (H5216-195-0) into this plan, so its members move here unless they choose otherwise. Every NM plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $20.00 |
|---|---|
| — medical (Part C) part | $9.00 |
| — drug (Part D) part | $11.00? |
| Monthly premium with full Extra Help (LIS) | $10.90?drug (Part D) part $1.90; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| In-network out-of-pocket maximum | $4,900.00? |
| In- and out-of-network out-of-pocket maximum | $10,100.00 |
| Drug deductible | $300.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | PPO? |
| Contract / plan | H5216-223-0 |
| Offered by | Humana |
| Parent organization | Humana Inc. |
| Formulary tiers | 5 |
| Formulary exception tier | 4? |
| Pharmacy search | www.humana.com/pharmacy/ |
| Member services | (888)873-0686TTY 711 |
CMS star ratings
- Overall
- 4 out of 5 stars for Overall
- Health plan (Part C)
- 4 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 4 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H5216 shares this rating.
Plan health benefits
| Service | In-network | Out-of-network? |
|---|---|---|
| Doctor visits | ||
| Primary care doctor | $0 copay | $30 copay |
| Specialist | $30 copay(authorization required) | $75 copay |
| Other health care professional | $0–$30 copay(authorization required) | $30–$75 copay |
| Additional telehealth services | $0–$50 copay | — |
| Preventive care | ||
| Medicare-covered preventive services | $0 copay | $0 copay |
| Annual physical exam | $0 copay | $0 copay |
| Kidney disease education | $0 copay | $0 copay |
| Glaucoma screening | $0 copay | $0 copay |
| Diabetes self-management training | $0 copay | $0 copay |
| Diagnostic tests, labs and imaging | ||
| Diagnostic tests and procedures | $0–$100 copay(authorization required) | $30–$75 copay; 40%–50% coinsurance |
| Lab services | $0 copay(authorization required) | $50 copay; 50% coinsurance |
| Diagnostic radiology (e.g. MRI, CT) | $0–$300 copay(authorization required) | $0–$500 copay; 50% coinsurance |
| Therapeutic radiology | $30 copay; 20% coinsurance(authorization required) | $75 copay; 50% coinsurance |
| Outpatient x-rays | $0–$50 copay(authorization required) | $30–$75 copay; 50% coinsurance |
| Emergency and urgent care | ||
| Emergency room | $115 copay | — |
| Urgent care | $50 copay | — |
| Worldwide emergency coverage | $115 copay | — |
| Worldwide urgent care | $50 copay | — |
| Worldwide emergency transportation | $325 copay | — |
| Hospital care | ||
| Inpatient hospital stay | $325 per day for days 1–6; $0 per day for days 7–90; $0 per day for days 91–999 (additional days)(authorization required) | $500 per day for days 1–20; $0 per day for days 21–90 |
| Outpatient hospital services | $0–$325 copay(authorization required) | $0–$75 copay; 40%–50% coinsurance |
| Outpatient observation | $325 copay(authorization required) | $500 copay |
| Ambulatory surgical center | $0–$225 copay(authorization required) | $0 copay; 40% coinsurance |
| Outpatient blood services | $0 copay(authorization required) | $0 copay |
| Skilled nursing and home health | ||
| Skilled nursing facility | $0 per day for days 1–20; $218 per day for days 21–100(authorization required) | 50% coinsurance per stay |
| Home health care | $0 copay(authorization required) | 50% coinsurance |
| Kidney dialysis | 20% coinsurance(authorization required) | 20% coinsurance |
| Rehabilitation | ||
| Occupational therapy | $30 copay(authorization required) | 40% coinsurance |
| Physical therapy and speech-language therapy | $30 copay(authorization required) | 40% coinsurance |
| Cardiac rehabilitation | $0 copay(authorization required) | 50% coinsurance |
| Pulmonary rehabilitation | $0 copay(authorization required) | 50% coinsurance |
| Mental health and substance use | ||
| Inpatient psychiatric hospital stay | $325 per day for days 1–6; $0 per day for days 7–90(authorization required) | $500 per day for days 1–20; $0 per day for days 21–90 |
| Outpatient mental health, individual session | $25 copay(authorization required) | 40% coinsurance |
| Outpatient mental health, group session | $25 copay(authorization required) | 40% coinsurance |
| Psychiatrist, individual session | $25 copay(authorization required) | 40% coinsurance |
| Psychiatrist, group session | $25 copay(authorization required) | 40% coinsurance |
| Partial hospitalization | $35 copay(authorization required) | 50% coinsurance |
| Intensive outpatient program | $35 copay(authorization required) | 50% coinsurance |
| Outpatient substance use, individual session | $25–$35 copay(authorization required) | 40% coinsurance |
| Outpatient substance use, group session | $25–$35 copay(authorization required) | 40% coinsurance |
| Opioid treatment program | $25–$35 copay(authorization required) | 40% coinsurance |
| Ambulance and transportation | ||
| Ground ambulance | $325 copay(authorization required) | $325 copay |
| Air ambulance | $630 copay(authorization required) | $630 copay |
| Transportation to plan-approved locations | Not covered | — |
| Medical equipment and supplies | ||
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) | 50% coinsurance |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) | 50% coinsurance |
| Medical supplies | 15% coinsurance(authorization required) | 50% coinsurance |
| Diabetes supplies | $0 copay; 10% coinsurance(authorization required) | 50% coinsurance |
| Diabetic therapeutic shoes or inserts | $10 copay(authorization required) | $10 copay |
| Chiropractic, acupuncture and foot care | ||
| Chiropractic (Medicare-covered) | $15 copay(authorization required) | 50% coinsurance |
| Routine chiropractic care | $15 copay(authorization required, limits apply) | $15 copay |
| Acupuncture | $30 copay(authorization required, limits apply) | $30 copay |
| Foot exams and treatment (Medicare-covered) | $30 copay(authorization required) | $75 copay |
| Routine foot care | $30 copay(authorization required, limits apply) | $30 copay |
| Dental? | ||
| Medicare-covered dental services | $30 copay(authorization required) | $75 copay |
| Preventive dental plan limit | $2,500 plan limit every year | — |
| Oral exams | $0 copay(limits apply) | $0 copay |
| Cleanings | $0 copay(limits apply) | $0 copay |
| Fluoride treatment | Not covered | — |
| Dental x-rays | $0 copay(limits apply) | $0 copay |
| Other diagnostic dental services | Not covered | — |
| Other preventive dental services | Not covered | — |
| Dentures and other removable prosthodontics | 50% coinsurance(authorization required, limits apply) | 50% coinsurance |
| Maxillofacial prosthetics | Not covered | — |
| Implants | Not covered | — |
| Orthodontics | Not covered | — |
| Adjunctive general services | 50% coinsurance(authorization required, limits apply) | 50% coinsurance |
| Vision? | ||
| Eye exam (Medicare-covered) | $0–$30 copay(authorization required, limits apply) | $0–$75 copay |
| Routine eye exam | $0 copay(authorization required, limits apply) | $0 copay |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(authorization required, limits apply) | $0 copay |
| Eyewear plan limit | $300 plan limit every year | — |
| Contact lenses | $0 copay(authorization required, limits apply) | $0 copay |
| Eyeglasses (frames and lenses) | $0 copay(authorization required, limits apply) | $0 copay |
| Eyeglass lenses | Not covered | — |
| Eyeglass frames | Not covered | — |
| Eyewear upgrades | Not covered | — |
| Hearing? | ||
| Hearing exam (Medicare-covered) | $30 copay(authorization required) | $75 copay |
| Routine hearing exam | $0 copay(authorization required, limits apply) | 95% coinsurance |
| Hearing aid fitting and evaluation | $0 copay(authorization required, limits apply) | 95% coinsurance |
| Hearing aids (all types) | $575–$750 copay(limits apply) | 95% coinsurance |
| Hearing aids, inner ear | Not covered | — |
| Hearing aids, outer ear | Not covered | — |
| Hearing aids, over the ear | Not covered | — |
| Medicare Part B drugs | ||
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) | 50% coinsurance |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 50% coinsurance |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 50% coinsurance |
| Other extra benefits? | ||
| Over-the-counter (OTC) allowance | Covered (allowance not stated) | — |
| Meals after a hospital stay or for a chronic condition | $0 copay(authorization required) | 95% coinsurance |
| Fitness benefit | Not covered | — |
| Health education | Not covered | — |
| Nutritional / dietary benefit | Not covered | — |
| Extra smoking and tobacco cessation counseling | Not covered | — |
| Enhanced disease management | Not covered | — |
| Telemonitoring | Not covered | — |
| Remote access technologies (web/phone, nurse line) | Not covered | — |
| Home and bathroom safety devices | Not covered | — |
| Counseling services | Not covered | — |
| In-home safety assessment | Not covered | — |
| Personal emergency response system (PERS) | Not covered | — |
| Medical nutrition therapy | Not covered | — |
| Post-discharge in-home medication reconciliation | Not covered | — |
| Re-admission prevention | Not covered | — |
| Wigs for hair loss from chemotherapy | Not covered | — |
| Weight management programs | Not covered | — |
| Alternative therapies | Not covered | — |
| Therapeutic massage | Not covered | — |
| Adult day health services | Not covered | — |
| Home-based palliative care | Not covered | — |
| In-home support services | Not covered | — |
| Support for caregivers | Not covered | — |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2027). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $8.00 |
| Tier 3 · Preferred Brand | 19% |
| Tier 4 · Non-Preferred Drug | 41% |
| Tier 5 · Specialty Tier | 30% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $8.00 | $8.00 | $8.00 | $24.00 | $24.00 | $0.00 |
| Tier 3: Preferred Brand | 19% | 19% | 19% | 19% | 19% | 17% |
| Tier 4: Non-Preferred Drug | 41% | 41% | 41% | 41% | 41% | 41% |
| Tier 5: Specialty Tier | 30% | 30% | 30% | n/a | n/a | n/a |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Star rating measures
| Measure | 2027 | 2026 |
|---|---|---|
| Staying Healthy: Screenings, Tests and Vaccines | ||
| Breast Cancer Screening · C01 | 4 out of 5 stars for Breast Cancer Screening | 4 out of 5 stars for Breast Cancer Screening |
| Colorectal Cancer Screening · C02 | 4 out of 5 stars for Colorectal Cancer Screening | 4 out of 5 stars for Colorectal Cancer Screening |
| Annual Flu Vaccine · C03 | 2 out of 5 stars for Annual Flu Vaccine | 4 out of 5 stars for Annual Flu Vaccine |
| Improving or Maintaining Physical Health · C04 | 2 out of 5 stars for Improving or Maintaining Physical Health | 2 out of 5 stars for Improving or Maintaining Physical Health |
| Improving or Maintaining Mental Health · C05 | 5 out of 5 stars for Improving or Maintaining Mental Health | 4 out of 5 stars for Improving or Maintaining Mental Health |
| Monitoring Physical Activity · C06 | 3 out of 5 stars for Monitoring Physical Activity | 3 out of 5 stars for Monitoring Physical Activity |
| Managing Chronic (Long Term) Conditions | ||
| Special Needs Plan (SNP) Care Management · C07 | 4 out of 5 stars for Special Needs Plan (SNP) Care Management | 4 out of 5 stars for Special Needs Plan (SNP) Care Management |
| Care for Older Adults – Medication Review · C08 | 5 out of 5 stars for Care for Older Adults – Medication Review | 5 out of 5 stars for Care for Older Adults – Medication Review |
| Care for Older Adults - Functional Status Assessment · C09 | 5 out of 5 stars for Care for Older Adults - Functional Status Assessment | new measure |
| Osteoporosis Management in Women who had a Fracture · C10 | 3 out of 5 stars for Osteoporosis Management in Women who had a Fracture | 2 out of 5 stars for Osteoporosis Management in Women who had a Fracture |
| Diabetes Care – Eye Exam · C11 | 3 out of 5 stars for Diabetes Care – Eye Exam | 3 out of 5 stars for Diabetes Care – Eye Exam |
| Diabetes Care – Blood Sugar Controlled · C12 | 5 out of 5 stars for Diabetes Care – Blood Sugar Controlled | 3 out of 5 stars for Diabetes Care – Blood Sugar Controlled |
| Kidney Health Evaluation for Patients with Diabetes · C13 | 3 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes | 3 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes |
| Controlling High Blood Pressure · C14 | 4 out of 5 stars for Controlling High Blood Pressure | 3 out of 5 stars for Controlling High Blood Pressure |
| Reducing the Risk of Falling · C15 | 3 out of 5 stars for Reducing the Risk of Falling | 3 out of 5 stars for Reducing the Risk of Falling |
| Improving Bladder Control · C16 | 2 out of 5 stars for Improving Bladder Control | 3 out of 5 stars for Improving Bladder Control |
| Plan All-Cause Readmissions · C17 | 4 out of 5 stars for Plan All-Cause Readmissions | 3 out of 5 stars for Plan All-Cause Readmissions |
| Statin Therapy for Patients with Cardiovascular Disease · C18 | 4 out of 5 stars for Statin Therapy for Patients with Cardiovascular Disease | 3 out of 5 stars for Statin Therapy for Patients with Cardiovascular Disease |
| Transitions of Care · C19 | 4 out of 5 stars for Transitions of Care | 4 out of 5 stars for Transitions of Care |
| Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions · C20 | 2 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions | 2 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions |
| Member Experience with Health Plan | ||
| Getting Needed Care · C21 | 3 out of 5 stars for Getting Needed Care | 4 out of 5 stars for Getting Needed Care |
| Getting Appointments and Care Quickly · C22 | 3 out of 5 stars for Getting Appointments and Care Quickly | 4 out of 5 stars for Getting Appointments and Care Quickly |
| Customer Service · C23 | 4 out of 5 stars for Customer Service | 4 out of 5 stars for Customer Service |
| Rating of Health Care Quality · C24 | 4 out of 5 stars for Rating of Health Care Quality | 4 out of 5 stars for Rating of Health Care Quality |
| Rating of Health Plan · C25 | 3 out of 5 stars for Rating of Health Plan | 2 out of 5 stars for Rating of Health Plan |
| Care Coordination · C26 | 4 out of 5 stars for Care Coordination | 4 out of 5 stars for Care Coordination |
| Member Complaints and Changes in the Health Plan's Performance | ||
| Complaints about the Health Plan · C27 | 4 out of 5 stars for Complaints about the Health Plan | 4 out of 5 stars for Complaints about the Health Plan |
| Members Choosing to Leave the Plan · C28 | 3 out of 5 stars for Members Choosing to Leave the Plan | 3 out of 5 stars for Members Choosing to Leave the Plan |
| Health Plan Quality Improvement · C29 | 4 out of 5 stars for Health Plan Quality Improvement | 4 out of 5 stars for Health Plan Quality Improvement |
| Health Plan Customer Service | ||
| Plan Makes Timely Decisions about Appeals · C30 | 5 out of 5 stars for Plan Makes Timely Decisions about Appeals | 4 out of 5 stars for Plan Makes Timely Decisions about Appeals |
| Reviewing Appeals Decisions · C31 | 4 out of 5 stars for Reviewing Appeals Decisions | 4 out of 5 stars for Reviewing Appeals Decisions |
| Call Center – Foreign Language Interpreter and TTY Availability · C32 | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD1: Drug Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · D01 | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD2: Member Complaints and Changes in the Drug Plan’s Performance | ||
| Complaints about the Drug Plan · D02 | 4 out of 5 stars for Complaints about the Drug Plan | 4 out of 5 stars for Complaints about the Drug Plan |
| Members Choosing to Leave the Plan · D03 | 3 out of 5 stars for Members Choosing to Leave the Plan | 3 out of 5 stars for Members Choosing to Leave the Plan |
| Drug Plan Quality Improvement · D04 | 4 out of 5 stars for Drug Plan Quality Improvement | 3 out of 5 stars for Drug Plan Quality Improvement |
| DD3: Member Experience with the Drug Plan | ||
| Rating of Drug Plan · D05 | 4 out of 5 stars for Rating of Drug Plan | 2 out of 5 stars for Rating of Drug Plan |
| Getting Needed Prescription Drugs · D06 | 4 out of 5 stars for Getting Needed Prescription Drugs | 4 out of 5 stars for Getting Needed Prescription Drugs |
| DD4: Drug Safety and Accuracy of Drug Pricing | ||
| MPF Price Accuracy · D07 | 1 out of 5 stars for MPF Price Accuracy | 1 out of 5 stars for MPF Price Accuracy |
| Medication Adherence for Diabetes Medications · D08 | 3 out of 5 stars for Medication Adherence for Diabetes Medications | 2 out of 5 stars for Medication Adherence for Diabetes Medications |
| Medication Adherence for Hypertension (RAS antagonists) · D09 | 4 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) | 3 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) |
| Medication Adherence for Cholesterol (Statins) · D10 | 4 out of 5 stars for Medication Adherence for Cholesterol (Statins) | 3 out of 5 stars for Medication Adherence for Cholesterol (Statins) |
| Statin Use in Persons with Diabetes (SUPD) · D11 | 2 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) | 3 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) |
| Concurrent Use of Opioids and Benzodiazepines (COB) · D12 | 4 out of 5 stars for Concurrent Use of Opioids and Benzodiazepines (COB) | new measure |
| Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) · D13 | 5 out of 5 stars for Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) | new measure |
Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H5216 shares it.
Also available in 25 other NM counties
Benefits in plain text
HumanaChoice H5216-223 (PPO) (H5216-223-0) is a 2027 PPO Medicare Advantage plan offered by Humana, available to residents of Rio Arriba County, NM.
The monthly premium is $20.00.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $10.90.
Its in-network out-of-pocket maximum is $4,900.00.
The combined in- and out-of-network out-of-pocket maximum is $10,100.00.
The drug deductible is $300.00. Tier 1 and 2 exempt.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): $8.00; tier 3 (Preferred Brand): 19%; tier 4 (Non-Preferred Drug): 41%; tier 5 (Specialty Tier): 30%.
CMS gives the plan's contract (H5216) an overall rating of 4 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.