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HumanaChoice Giveback H5216-264 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice Giveback H5216-264 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice Giveback H5216-264 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice Giveback H5216-264 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Arkansas and Oklahoma. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice Giveback H5216-264 (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 H5216-264 (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 H5216-264 (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 $100.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $375.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $590.00 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 $11000.00 (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 $11000.00 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 H5216-264 (PPO) plan has a $590 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy type. For example, you'll pay an $8 copay for preferred generic drugs at a preferred pharmacy, or 47% coinsurance for preferred brand drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The HumanaChoice Giveback H5216-264 (PPO) plan offers a range of benefits with varying cost structures. Inpatient hospital stays have copays depending on the days, and outpatient services have copays that vary by the service. Emergency and primary care services have copays, and preventive services are covered with no copay. The plan includes coverage for hearing and vision services, with copays for hearing exams and eye exams, and no copay for eyewear. Dental services are covered with a $50 copay for Medicare Dental Services, and other services like ambulance, home infusion, and dialysis have copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits for HumanaChoice Giveback H5216-264 (PPO) include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with a copay of $360 for days 1-6 and no copay for days 7-90 for Inpatient Hospital-Acute, and a copay of $318 for days 1-6 and no copay for days 7-90 for Inpatient Hospital Psychiatric. Additional days for Inpatient Hospital-Acute have no copay, and Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a copay between $0 and $360, while observation services have a $360 copay. Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services have no copay, while Individual and Group Sessions for Outpatient Substance Abuse have a copay between $10 and $40.
Partial Hospitalization See details
Partial Hospitalization is covered under this plan with a $40 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered. Ground ambulance services have a $315 copay, while air ambulance services have a 20% 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 under the HumanaChoice Giveback H5216-264 (PPO) plan. Emergency Services and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation have a $110 copay, and Urgently Needed Services has a $45 copay; all have no coinsurance.
Primary Care See details
The HumanaChoice Giveback H5216-264 (PPO) plan's primary care benefit covers primary care physician services with a $10 copay, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, physician specialist services with a $50 copay, and mental health specialty services with a $10 copay for individual and group sessions. The plan also covers physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits with a copay between $0 and $50, and opioid treatment program services with a copay between $10 and $40. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The HumanaChoice Giveback H5216-264 (PPO) plan covers preventive services, including an annual physical exam with no copay. Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit also have no copay. However, Health Education, In-Home Safety Assessment, Personal Emergency Response System, Medical Nutrition Therapy, 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 Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, 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 under this plan with a $50 copay, and routine hearing exams are covered with no copay for up to one exam per year. Prescription hearing aids are partially covered under this plan, with a copay between $699 and $999 for prescription hearing aids (all types), but prescription hearing aids (inner ear, outer ear, and over the ear) are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a copay of $0-$50, and eyewear has no copay. Contact lenses and eyeglasses (lenses and frames) are covered, and have no copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice Giveback H5216-264 (PPO) plan covers Medicare Dental Services with a $50 copay, oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics fixed, and oral and maxillofacial surgery with no copay. Fluoride treatment, prosthodontics removable, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay, and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice Giveback H5216-264 (PPO) plan, but require prior authorization. The coinsurance for Dialysis Services is 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 5% coinsurance, while Diabetic Equipment includes a 5% coinsurance and a $0-$10 copay depending on the service.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests have a copay between $0 and $90, while Lab Services have no copay. Diagnostic Radiological Services have a copay of up to $360, Therapeutic Radiological Services have a copay of $50, and Outpatient X-Ray Services have a $10 copay.
Home Health Services See details
Home Health Services are covered under the HumanaChoice Giveback H5216-264 (PPO) plan, with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
HumanaChoice Giveback H5216-264 (PPO) 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 HumanaChoice Giveback H5216-264 (PPO) with prior authorization. There is no copay for days 1-20, but there is a $214 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The HumanaChoice Giveback H5216-264 (PPO) plan covers acupuncture with a $50 copay and a limit of 20 treatments per year, and meal benefits 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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