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HumanaChoice Giveback H5216-017 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice Giveback H5216-017 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice Giveback H5216-017 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice Giveback H5216-017 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in North Carolina. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice Giveback H5216-017 (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 Giveback H5216-017 (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 Giveback H5216-017 (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 $84.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $350.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $450.00 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 $14000.00 (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 $14000.00 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 Giveback H5216-017 (PPO) plan has a $450 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy. For example, in the initial coverage phase, you will pay a $5 copay for preferred generic drugs at a standard or preferred mail pharmacy, and a 50% coinsurance for preferred brand drugs. Once your total drug costs reach $2000, you will enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice Giveback H5216-017 (PPO) plan offers comprehensive coverage, including inpatient and outpatient hospital services with varying copays. You'll have no copay for primary care visits, and many preventive services, while other services like specialist visits and hearing exams have copays. Emergency services and ambulance services are covered with copays, and the plan also includes coverage for home health, and skilled nursing facility services. This plan provides additional benefits such as hearing and vision services with copays, and dental services with no copay for certain services. Medical equipment, diagnostic services, and cardiac rehabilitation services are also covered, with associated copays or coinsurance. However, be aware that some services like certain dental, vision, and hearing options, and some additional services, are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered. For Inpatient Hospital-Acute, you pay a $475 copay for days 1-5, and no copay for days 6-90, with no coinsurance; additional days 91-999 have no copay. Inpatient Hospital Psychiatric has a $475 copay for days 1-4, and no copay for days 5-90, with no coinsurance. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and additional days for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay between $0 and $450, observation services with a $475 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a copay between $45 and $100, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered with a $80 copay. Prior authorization is required.
Ambulance and Transportation Services See details
For HumanaChoice Giveback H5216-017 (PPO), all ambulance services are covered, with a $315 copay for both ground and air ambulance services, and no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation have a $110 copay, while Urgently Needed Services have a $45 copay; all have no coinsurance.
Primary Care See details
The HumanaChoice Giveback H5216-017 (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, and occupational therapy services with a $25 copay. The plan also covers physician specialist services with a $55 copay, and physical therapy and speech-language pathology services with a $25 copay. The plan's mental health specialty services, psychiatric services, and opioid treatment program services have a copay ranging from $45 to $100, and additional telehealth benefits range from no copay to a $55 copay. Podiatry services are not covered.
Preventive Services See details
The HumanaChoice Giveback H5216-017 (PPO) plan covers preventive services, including an annual physical exam with no copay. The plan also covers kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit, all with no copay. However, health education, in-home safety assessment, personal emergency response systems (PERS), medical nutrition therapy (MNT), post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, fitness benefits, enhanced disease management, telemonitoring services, remote access technologies, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
Hearing exams are covered with a $55 copay, while routine hearing exams and fitting/evaluation for hearing aids have no copay. Prescription hearing aids are covered, with a copay between $699 and $999 for all types of prescription hearing aids, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$55, and a maximum plan benefit of $75 per year. Eyewear is also covered with no copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice Giveback H5216-017 (PPO) plan covers Medicare Dental Services with a $55 copay, Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), and Other Preventive Dental Services with no copay. Fluoride Treatment, Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the HumanaChoice Giveback H5216-017 (PPO) plan, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, with coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice Giveback H5216-017 (PPO) plan and require prior authorization. The coinsurance for Dialysis Services is between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with 12% coinsurance, Prosthetics/Medical Supplies with 12% coinsurance, and Diabetic Equipment with varying coinsurance and copays. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures and tests with a copay between $0 and $120, lab services with no copay, and outpatient X-ray services with no copay. Diagnostic and therapeutic radiological services have a copay, and therapeutic radiological services have 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the HumanaChoice Giveback H5216-017 (PPO) plan with no copay and no coinsurance. However, Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the HumanaChoice Giveback H5216-017 (PPO) plan, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice Giveback H5216-017 (PPO) plan, with a $0 copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services include acupuncture, which has a $55 copay for up to 20 treatments per year, and a meal benefit with no copay. Over-the-counter items, 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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