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HumanaChoice Giveback H5216-138 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice Giveback H5216-138 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice Giveback H5216-138 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice Giveback H5216-138 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in ME and NH. Select Counties in CT, MA, and VT. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice Giveback H5216-138 (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 H5216-138 (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 H5216-138 (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 $55.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $540.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $395.00 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 $7750.00 (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 $7750.00 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 H5216-138 (PPO) plan has a $395.00 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, in the initial coverage phase, you'll pay a $5 copay for preferred generic drugs at a standard or preferred mail pharmacy, and a $20 copay at a standard mail pharmacy. For preferred brand drugs, you will pay 50% coinsurance. After your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The HumanaChoice Giveback H5216-138 (PPO) plan offers comprehensive coverage including inpatient and outpatient hospital services with varying copays. You'll find no copays for primary care visits, many preventive services, and some vision and dental services. The plan also includes coverage for ambulance services, emergency services, and other services like hearing exams and home health services, some with copays and coinsurance. Additional benefits include a meal benefit, and a range of other services with varying cost-sharing requirements.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $445 copay for days 1-6, and no copay for days 7-90, and for Inpatient Hospital Psychiatric, you will pay a $380 copay for days 1-6, and no copay for days 7-90. Additional days for Inpatient Hospital-Acute are covered with no copay for days 91-999. Non-Medicare-covered stay 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 include coverage for Outpatient Hospital Services with a copay of $50-$550, Observation Services with a copay of $445, Ambulatory Surgical Center (ASC) Services with a copay of $400, Individual and Group Sessions for Outpatient Substance Abuse with a copay of $45-$100, and Outpatient Blood Services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice Giveback H5216-138 (PPO) plan, with a $55 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including both ground and air ambulance services with a copay of $315.00. Transportation services to a plan-approved health-related location are also covered with no copay for up to 24 one-way trips per year, but transportation services to any health-related location are not covered.
Emergency Services See details
Emergency services are covered by the HumanaChoice Giveback H5216-138 (PPO) plan, with a $125 copay and no coinsurance; urgently needed services have a $55 copay and no coinsurance; and worldwide emergency services have a $125 copay and no coinsurance for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation.
Primary Care See details
The HumanaChoice Giveback H5216-138 (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $40 copay, and physician specialist services with a $50 copay. The plan also covers mental health specialty services, psychiatric services, and opioid treatment program services with copays ranging from $45 to $100, and physical therapy and speech-language pathology services with a $40 copay. Additional telehealth benefits have a copay range of $0 to $55. Routine chiropractic care is not covered, and podiatry services are not covered.
Preventive Services See details
Preventive services include Medicare-covered zero dollar services, annual physical exams with no copay, additional preventive services with a copay, kidney disease education services, and other preventive services with no copay for glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit. Health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, readmission 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, 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 Services include hearing exams with a $50 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $699 and $999, but prescription hearing aids - inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$50, and eyewear with no copay. Contact lenses and eyeglasses (lenses and frames) are covered with no copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice Giveback H5216-138 (PPO) plan covers Medicare Dental Services with a $50 copay, and other dental services including 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, maxillofacial prosthetics, implant services, prosthodontics (fixed), oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice Giveback H5216-138 (PPO) plan and require prior authorization. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered. DME has a 4% coinsurance, while Prosthetic Devices have a 9% coinsurance, and Medical Supplies have a 10% coinsurance. Diabetic Supplies have between a 4-10% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services with a copay, and lab services with no copay. Diagnostic Procedures/Tests have a copay between $0 and $100, and Diagnostic Radiological Services have a copay between $50 and $400. Therapeutic Radiological Services have 20% coinsurance, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice Giveback H5216-138 (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover any of the sub-services, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the HumanaChoice Giveback H5216-138 (PPO) plan, with a copay of $10 for days 1-20 and a copay of $214 for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include acupuncture, a meal benefit, and more. Acupuncture has a $50 copay per visit with a limit of 20 treatments per year, while the meal benefit has no copay.
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