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HumanaChoice Giveback H5216-409 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice Giveback H5216-409 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice Giveback H5216-409 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice Giveback H5216-409 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Wichita. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice Giveback H5216-409 (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 H5216-409 (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 H5216-409 (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 $56.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $500.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $250.00 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 H5216-409 (PPO) plan has a $250 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For generic drugs, you can expect to pay a $10 or $20 copay, depending on the pharmacy. For preferred brand drugs, you pay 48% coinsurance, and for non-preferred drugs, you pay 30% coinsurance. After your yearly out-of-pocket drug costs reach $2000, you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice Giveback H5216-409 (PPO) plan offers a range of benefits, including coverage for inpatient hospital stays with a copay, outpatient services with varying copays, and emergency services. Primary care visits have no copay, and preventive services are covered with no copay as well. The plan also includes coverage for hearing exams, vision exams and eyewear, and a wide array of dental services, most of which have no copay. In addition to the above, this plan covers home health services, cardiac rehabilitation, and skilled nursing facility stays, each with varying copays or coinsurance. It also includes benefits for ambulance services, home infusion services, and medical equipment. The plan offers additional services such as acupuncture and over-the-counter items, both with a maximum benefit, and has a meal benefit with no copay.
Inpatient Hospital See details
Inpatient Hospital benefits are covered by the HumanaChoice Giveback H5216-409 (PPO) plan. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you will pay a $450 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute have no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered. Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $300, observation services with a $450 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services have a $40 copay for both individual and group sessions, and outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under this plan with a $35 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice Giveback H5216-409 (PPO) plan. 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, including Urgently Needed Services and Worldwide Emergency Services, are covered by the HumanaChoice Giveback H5216-409 (PPO) plan. Emergency Services have a $125 copay, while Urgently Needed Services have a $55 copay, and there is no coinsurance for either service. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $125 copay.
Primary Care See details
HumanaChoice Giveback H5216-409 (PPO) covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $45 copay, physician specialist services with a $45 copay, mental health and psychiatric services with a $45 copay, physical therapy and speech-language pathology services with a $45 copay, additional telehealth benefits with a copay between $0 and $55, and opioid treatment program services with a $40 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, as well as an annual physical exam with no copay. Additional preventive services, including Fitness Benefit, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, are also covered with no copay. However, Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing exams are covered with a $45 copay. Routine hearing exams have no copay, and you are allowed one exam every year. Fitting/evaluation for hearing aids have no copay. Prescription hearing aids are partially covered, with hearing aids for inner ear, outer ear, and over the ear not covered. OTC hearing aids are covered with a maximum benefit of $125 every three months.
Vision Services See details
The HumanaChoice Giveback H5216-409 (PPO) plan covers vision services, including eye exams with a copay of $0-$45 per year, and eyewear, including contact lenses and eyeglasses with a copay of $0, but does not cover eyeglass lenses, eyeglass frames, or upgrades. The plan has a combined maximum of $200 for all eyewear every year.
Dental Services See details
The HumanaChoice Giveback H5216-409 (PPO) plan covers a range of dental services, including oral exams with no copay, dental x-rays with no copay, and other diagnostic dental services with no copay. Other services include prophylaxis (cleaning) with no copay, restorative services with no copay, adjunctive general services with no copay, endodontics with no copay, periodontics with no copay, prosthodontics (removable) with a 30% coinsurance, prosthodontics (fixed) with a 30% coinsurance, and oral and maxillofacial surgery with no copay. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, as well as Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, both with 0-20% coinsurance. Prior authorization is required for this benefit.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice Giveback H5216-409 (PPO) plan, with a coinsurance between 20% and 20%. Prior authorization is required for this benefit.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment, which has no copay and a 1% to 1% coinsurance, but does not cover Durable Medical Equipment for use outside the home. Prosthetics/Medical Supplies have no copay and are subject to coinsurance. Medical Supplies have a 20% coinsurance, while Prosthetic Devices have a 20% coinsurance. Diabetic Equipment has a coinsurance and copay, and Diabetic Supplies have no copay and a 10% to 20% coinsurance. Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the HumanaChoice Giveback H5216-409 (PPO) plan. Diagnostic Procedures/Tests have a coinsurance of at most 20% and a copay of up to $55, while Lab Services have no copay. Diagnostic Radiological Services have a copay of up to $450, and Therapeutic Radiological Services have a copay of up to $40. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice Giveback H5216-409 (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization is required, and there is a copay.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice Giveback H5216-409 (PPO) plan, with a copay of $10 for days 1-20 and $203 for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The HumanaChoice Giveback H5216-409 (PPO) plan covers acupuncture with a $45 copay, up to 20 treatments per year, and also covers over-the-counter items with a $125 maximum benefit every three months. The plan also includes a meal benefit with no copay, and some additional services are not covered.
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