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HumanaChoice Giveback H5216-403 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice Giveback H5216-403 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice Giveback H5216-403 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice Giveback H5216-403 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Illinois. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice Giveback H5216-403 (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 H5216-403 (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 H5216-403 (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 $71.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $750.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $615.00 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 $10100.00 (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 $10100.00 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 H5216-403 (PPO) plan features an annual drug deductible of $615. For Tier 1 preferred generic drugs, members pay 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, with no copay for a 3-month supply when using preferred mail order. Tier 3 preferred brand drugs require a $47 copay for a 1-month supply across standard retail pharmacies and mail-order options. For higher-tier medications, the plan charges a 50% coinsurance for Tier 4 non-preferred drugs and a 25% coinsurance for Tier 5 specialty drugs.
Additional Benefits
The HumanaChoice Giveback H5216-403 (PPO) plan offers comprehensive medical coverage, featuring no copay and no coinsurance for primary care visits, preventive services, home health care, and routine vision and dental exams. For specialist visits, physical therapy, and acupuncture, members pay a $40 copay with no coinsurance. Inpatient hospital stays require a $450 daily copay for the first five days and no copay thereafter, while emergency room visits have a $130 copay that is waived if admitted. Routine hearing exams and over-the-counter hearing aids are available with no copay, while prescription hearing aids require copays between $199 and $799. Skilled nursing facility stays have a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100 with no coinsurance. Durable medical equipment and dialysis services generally require a 20% coinsurance with no copay, and dental services are covered up to a $2,500 annual limit.
Inpatient Hospital See details
Inpatient hospital benefits under the HumanaChoice Giveback H5216-403 (PPO) are partially covered with no coinsurance and require prior authorization. Covered acute and psychiatric stays require a $450 daily copay for days 1 through 5 and no copay for days 6 through 90, though upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice Giveback H5216-403 (PPO) covers outpatient services with no coinsurance, including outpatient hospital services with a $0 to $300 copay and observation services with a $450 copay per stay. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions require a $30 to $35 copay and no coinsurance.
Partial Hospitalization See details
HumanaChoice Giveback H5216-403 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
HumanaChoice Giveback H5216-403 (PPO) covers ground ambulance services with a $335 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, both of which require prior authorization. Transportation services to plan-approved or other health-related locations are not covered.
Emergency Services See details
HumanaChoice Giveback H5216-403 (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 have a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $130 copay and no coinsurance.
Primary Care See details
HumanaChoice Giveback H5216-403 (PPO) provides primary care physician services with no copay and no coinsurance, while specialist visits, occupational therapy, and physical therapy require a $40 copay and no coinsurance. Mental health and psychiatric services carry a $30 copay and no coinsurance, but podiatry is not covered, and chiropractic services are only partially covered with routine and other chiropractic services not covered.
Preventive Services See details
HumanaChoice Giveback H5216-403 (PPO) preventive services are covered with no copay and no coinsurance, including annual physical exams, kidney disease education, and glaucoma screenings. Additional preventive services are partially covered, offering a memory fitness benefit with no copay, while sub-services such as health education, in-home safety assessments, personal emergency response systems, weight management programs, and nutritional/dietary benefits are not covered.
Hearing Services See details
HumanaChoice Giveback H5216-403 (PPO) covers hearing exams with a $40 copay for Medicare-covered exams and no copay for routine annual exams and fittings, all with no coinsurance. Prescription hearing aids are partially covered with copays ranging from $199 to $799 and no coinsurance, excluding inner ear, outer ear, and over-the-ear types, while over-the-counter hearing aids are covered with no copay or coinsurance.
Vision Services See details
HumanaChoice Giveback H5216-403 (PPO) partially covers vision services, providing routine eye exams, contact lenses, and eyeglasses (lenses and frames) with no copay, no coinsurance, and no deductible. However, other eye exam services, eyeglass lenses, eyeglass frames, and upgrades are not covered under this plan.
Dental Services See details
HumanaChoice Giveback H5216-403 (PPO) partially covers dental services up to a $2,500 annual limit, offering most preventive and comprehensive care with no copay and no coinsurance. Medicare-covered dental services require a $40 copay (no coinsurance), prosthodontics require a 30% coinsurance (no copay), and fluoride, implants, orthodontics, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by HumanaChoice Giveback H5216-403 (PPO) with no copay, though prior authorization is required. Medicare Part B chemotherapy, insulin, and other drugs feature a coinsurance ranging from no coinsurance up to 20%, with insulin also requiring a $35 copay.
Dialysis Services See details
HumanaChoice Giveback H5216-403 (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required for these covered services.
Medical Equipment See details
Medical equipment is covered by HumanaChoice Giveback H5216-403 (PPO), with durable medical equipment, prosthetics, and medical supplies requiring a 20% coinsurance and no copay. Diabetic supplies are covered with a 10% coinsurance and no copay, while diabetic therapeutic shoes or inserts require a $10 copay.
Diagnostic and Radiological Services See details
HumanaChoice Giveback H5216-403 (PPO) covers diagnostic and radiological services with prior authorization, offering lab services and outpatient X-rays with no copay. Outpatient diagnostic procedures and tests have no coinsurance and a copay ranging from $0 to $95, while diagnostic radiological services have a $0 minimum copay and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home health services are covered by HumanaChoice Giveback H5216-403 (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are not covered under the HumanaChoice Giveback H5216-403 (PPO) plan, as none of the individual sub-services—including intensive cardiac, pulmonary, and SET for PAD rehabilitation—are covered in practice.
Skilled Nursing Facility (SNF) See details
HumanaChoice Giveback H5216-403 (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, a prior three-day hospital stay is not required, and additional days beyond the standard 100 days are not covered.
Other Services See details
HumanaChoice Giveback H5216-403 (PPO) partially covers other services, offering acupuncture for a $40 copay and no coinsurance for up to 20 treatments per year with prior authorization. Over-the-counter (OTC) items and limited meal benefits for chronic illnesses are also covered with no copay and no coinsurance, while other miscellaneous services are not covered.
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