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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 2026, 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 2026.
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 $61.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $675.00 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) prescription drug plan has an annual drug deductible of $395. For Tier 1 preferred generic drugs, there is no copay for a 1-month or 3-month supply at standard pharmacies and through preferred mail order. Tier 2 generic drugs cost a $5 copay for a 1-month supply at standard pharmacies and preferred mail order, and there is no copay for a 3-month supply through preferred mail order. Tier 3 preferred brand drugs have a $47 copay for a 1-month supply, while a 3-month supply costs $131 through preferred mail order or $141 through standard options. For higher-tier medications, Tier 4 non-preferred drugs require a 44% coinsurance, and Tier 5 specialty drugs require a 28% coinsurance for a 1-month supply.
Additional Benefits
The HumanaChoice Giveback H5216-138 (PPO) plan offers robust coverage for core medical needs, featuring no copay and no coinsurance for primary care visits and preventive services. Specialists are available for a $45 copay, while inpatient acute hospital stays require a $445 daily copay for the first six days with no coinsurance. Emergency room visits carry a $130 copay, which is waived if you are admitted, and emergency ambulance services require a $335 copay. This plan also provides valuable supplemental benefits, including no copay for routine dental care, annual eye exams, and routine hearing exams. Prescription hearing aids are covered with copays ranging from $699 to $999, while home health services and up to 24 one-way transportation trips are available with no copay. Durable medical equipment and dialysis services are covered with a 20% coinsurance and no copay.
Inpatient Hospital See details
HumanaChoice Giveback H5216-138 (PPO) covers inpatient acute hospital stays with no coinsurance and a $445 daily copay for days 1 through 6, and psychiatric stays with no coinsurance and a $380 daily copay for days 1 through 6, followed by no copay for days 7 through 90. Unlimited additional acute care days are covered at no copay, but additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
HumanaChoice Giveback H5216-138 (PPO) covers outpatient services with no coinsurance, offering ambulatory surgical center and blood services with no copays. Outpatient hospital services require a copay ranging from $0 to $575, with a $445 copay per stay for observation services, while individual and group substance abuse sessions have a $35 copay.
Partial Hospitalization See details
Partial hospitalization is covered by the HumanaChoice Giveback H5216-138 (PPO) plan with a $35 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
HumanaChoice Giveback H5216-138 (PPO) covers emergency ambulance services with a $335 copay and no coinsurance for both ground and air transportation. Transportation services are partially covered, offering up to 24 one-way trips per year to plan-approved locations with no copay or coinsurance, though transportation to any health-related location is not covered.
Emergency Services See details
HumanaChoice Giveback H5216-138 (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services are covered with a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services require a $130 copay and no coinsurance. These costs do not count toward any plan-level deductible.
Primary Care See details
HumanaChoice Giveback H5216-138 (PPO) covers primary care with no copay and no coinsurance, specialists for a $45 copay and no coinsurance, and therapy services for a $40 copay and no coinsurance. Mental health, psychiatric, and opioid treatments require a $35 copay and no coinsurance, telehealth ranges from no copay to a $50 copay and no coinsurance, podiatry is not covered, and while some chiropractic services are covered for a $15 copay and no coinsurance, routine and other chiropractic services are not covered.
Preventive Services See details
Preventive services under the HumanaChoice Giveback H5216-138 (PPO) are partially covered with no copay and no coinsurance for covered services, including annual physical exams, kidney disease education, glaucoma screenings, and a memory fitness benefit. However, several supplemental benefits are not covered, such as health education, nutritional/dietary benefits, in-home safety assessments, and personal emergency response systems.
Hearing Services See details
HumanaChoice Giveback H5216-138 (PPO) covers routine hearing exams and fitting evaluations with no copay and no coinsurance, while Medicare-covered exams require a $45 copay and no coinsurance. Prescription hearing aids are partially covered with a copay ranging from $699 to $999 and no coinsurance for up to two devices per year, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
HumanaChoice Giveback H5216-138 (PPO) provides partially covered vision services with no coinsurance, including one routine eye exam and one pair of eyeglasses or contact lenses per year with no copay. Annual maximum benefits apply up to $75 for exams and $200 for eyewear, while other eye exams, separate eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice Giveback H5216-138 (PPO) dental services are partially covered, with Medicare-covered dental services requiring a $45 copay and no coinsurance, and other covered dental services requiring no copay and no coinsurance. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
HumanaChoice Giveback H5216-138 (PPO) covers Home Infusion bundled Services with no copay and no coinsurance, subject to prior authorization. Under this benefit, Medicare Part B chemotherapy and other Part B drugs have no copay and a coinsurance of no coinsurance to 20%, while Part B insulin is covered with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by the HumanaChoice Giveback H5216-138 (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Medical equipment is covered by HumanaChoice Giveback H5216-138 (PPO), requiring a 20% coinsurance and no copay for durable medical equipment, prosthetics, and medical supplies. Diabetic supplies feature a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes and inserts require a $10 copay, with prior authorization required for these services.
Diagnostic and Radiological Services See details
HumanaChoice Giveback H5216-138 (PPO) covers diagnostic and radiological services with no coinsurance for diagnostic services and no copay for lab and outpatient X-ray services. Outpatient diagnostic procedures and tests have a copay ranging from $0 to $100, while therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the HumanaChoice Giveback H5216-138 (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
HumanaChoice Giveback H5216-138 (PPO) covers some cardiac rehabilitation services with no coinsurance, though key sub-services such as standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation are not covered and require copays ranging from $15 to $40.
Skilled Nursing Facility (SNF) See details
HumanaChoice Giveback H5216-138 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required for these services, and additional days beyond the standard 100-day Medicare-covered limit are not covered.
Other Services See details
HumanaChoice Giveback H5216-138 (PPO) partially covers other services, offering acupuncture with a $45 copay and no coinsurance for up to 20 treatments per year, and meal benefits for chronic illnesses with no copay and no coinsurance. Over-the-counter (OTC) items are not covered under this plan.
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