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HumanaChoice Giveback H5216-406 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice Giveback H5216-406 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice Giveback H5216-406 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice Giveback H5216-406 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Virginia. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice Giveback H5216-406 (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 H5216-406 (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 H5216-406 (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 $99.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $400.00 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 H5216-406 (PPO) plan has a $450 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, in the initial coverage phase, you will pay a $0 copay for preferred generic drugs at a standard pharmacy, and a $20 copay at a standard mail pharmacy. The plan enters the catastrophic coverage phase after your total drug costs reach $2000, at which point you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice Giveback H5216-406 (PPO) plan offers comprehensive coverage, including inpatient and outpatient hospital services, with varying copays. Emergency, primary care, and preventive services are covered, often with low copays or no copay. The plan also includes dental, vision, and hearing benefits, as well as coverage for home health, skilled nursing, and other services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $385 copay for days 1-5, and no copay for days 6-90, and additional days 91-999 have no copay; Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered. For Inpatient Hospital Psychiatric, you will pay a $385 copay for days 1-4, and no copay for days 5-90, while additional days and non-Medicare covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a copay of $0 to $450; observation services with a copay of $385; and ambulatory surgical center (ASC) services with no copay. Outpatient substance abuse services have a copay between $45 and $100 for individual and group sessions, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice Giveback H5216-406 (PPO) plan, but requires prior authorization. The copay for this service is $80.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground and air ambulance services have a copay of $315, and there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Services, are covered by the HumanaChoice Giveback H5216-406 (PPO) plan. Emergency Services have a $110 copay, Urgently Needed Services have a $45 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $110 copay.
Primary Care See details
The HumanaChoice Giveback H5216-406 (PPO) plan covers primary care physician services with a $10 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, mental health specialty services with a $45 copay, and physical therapy and speech-language pathology services with a $25 copay. Additional telehealth benefits have a copay that ranges from $0 to $55, and opioid treatment program services has a copay that ranges from $45 to $100. However, routine chiropractic care is not covered, and podiatry services are not covered.
Preventive Services See details
The HumanaChoice Giveback H5216-406 (PPO) plan covers preventive services, including an annual physical exam with no copay. Kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit are covered with no copay. However, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and several other services are not covered.
Hearing Services See details
HumanaChoice Giveback H5216-406 (PPO) covers hearing exams for a $55 copay, routine hearing exams with no copay for 1 visit per year, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a copay of $699-$999 for all types of prescription hearing aids, but inner ear, outer ear, and over the ear prescription hearing aids are not covered, and OTC hearing aids are also not covered.
Vision Services See details
The HumanaChoice Giveback H5216-406 (PPO) plan covers vision services, including eye exams with a copay of $0-$55. Eyewear is covered with no copay, and contact lenses and eyeglasses are covered with no copay. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services include a $55 copay for Medicare dental services, with a $1500 maximum benefit per year for both in-network and out-of-network services. 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 are covered with no copay, but have visit limits and other restrictions. 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, and prior authorization is required. 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 with a coinsurance of 20%. Prior authorization is required.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 14% coinsurance and Prosthetics/Medical Supplies with 15% coinsurance. Diabetic Supplies have a 10-20% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the HumanaChoice Giveback H5216-406 (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $120, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $325, and Therapeutic Radiological Services have a copay of at most $55 with coinsurance of at most 20%. Outpatient X-Ray Services have a $10 copay.
Home Health Services See details
Home Health Services are covered with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice Giveback H5216-406 (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
The HumanaChoice Giveback H5216-406 (PPO) plan covers acupuncture with a $55 copay and a limit of 20 treatments per year, and it also covers 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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