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HumanaChoice Giveback H5216-424 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice Giveback H5216-424 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice Giveback H5216-424 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice Giveback H5216-424 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Massachusetts. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice Giveback H5216-424 (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 H5216-424 (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 H5216-424 (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 $45.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $475.00 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 H5216-424 (PPO) plan has a $395.00 deductible. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For generic drugs at a standard pharmacy, you will pay a $5.00 copay for preferred generics and a $47.00 copay for standard generics. For brand-name drugs, you will pay 50% coinsurance. Once your total yearly out-of-pocket drug costs reach $2000.00, you will enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The HumanaChoice Giveback H5216-424 (PPO) plan offers a range of benefits, including inpatient hospital care with copays ranging from $380 to $445, and outpatient services with copays from $0 to $550. This plan also covers emergency services, ambulance services, and transportation with varying copays, as well as primary care, preventive, hearing, vision, and dental services with specific copays or coinsurance amounts. Additional benefits include coverage for partial hospitalization, home health services with no copay, and skilled nursing facility care with copays depending on the length of stay. The plan also covers diagnostic and radiological services, medical equipment, and home infusion services, each with their own copay or coinsurance structure.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care. For Inpatient Hospital-Acute, you'll pay a $445 copay for days 1-6 and no copay for days 7-90, and for Additional Days for Inpatient Hospital-Acute, you'll have no copay for days 91-999. Inpatient Hospital Psychiatric has a $380 copay for days 1-6 and no copay for days 7-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Additional Days for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
The HumanaChoice Giveback H5216-424 (PPO) plan covers outpatient services, including outpatient hospital services with a copay of $50-$550, observation services with a $445 copay, and ambulatory surgical center services with a $400 copay. Outpatient substance abuse services have a copay between $45-$100 for individual and group sessions, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered with a $55 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the HumanaChoice Giveback H5216-424 (PPO) plan. Ground and air ambulance services have a $315 copay, while transportation services to a plan-approved health-related location have no copay for up to 24 one-way trips per year, using taxis, buses, subways, or medical transport.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the HumanaChoice Giveback H5216-424 (PPO) plan. Emergency Services has a $125 copay, Urgently Needed Services has a $45 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $125 copay.
Primary Care See details
Primary Care Physician Services have no copay, while Chiropractic Services have a $15 copay. Occupational Therapy Services have a $40 copay, and Physician Specialist Services have a $50 copay. Individual and Group Sessions for Mental Health and Psychiatric Services have a $45 copay, Physical Therapy and Speech-Language Pathology Services have a $40 copay, and Opioid Treatment Program Services have a copay between $45 and $100. Additional Telehealth Benefits have a copay between $0 and $50. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
The HumanaChoice Giveback H5216-424 (PPO) plan covers preventive services, including an annual physical exam with no copay. This plan's additional preventive services are not covered, but other preventive services such as glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit have no copay.
Hearing Services See details
Hearing exams are covered with a $50 copay, while routine hearing exams are covered with no copay for one exam per year. Fitting/evaluation for hearing aids are covered with no copay, and prescription hearing aids are covered with a copay between $699 and $999 for two per year, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
The HumanaChoice Giveback H5216-424 (PPO) plan covers vision services, including routine eye exams with a copay of $0-$50, and eyewear. Eyewear includes contact lenses and eyeglasses (lenses and frames) with no copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice Giveback H5216-424 (PPO) plan covers Medicare dental services with a $50 copay, while other dental services are covered with a maximum benefit of $4,000 per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and other preventive dental services are covered with no copay; however, fluoride treatment, orthodontics, and some services like prosthodontics and implant services are not covered. Restorative services and prosthodontics, fixed have a coinsurance of 30% - 40%, and endodontics, periodontics, and oral and maxillofacial surgery are covered with no copay.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, requiring prior authorization. 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 under the HumanaChoice Giveback H5216-424 (PPO) plan, but require prior authorization. The coinsurance for Dialysis Services is 20%.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered. DME has a 9% coinsurance, while Prosthetic Devices also has a 9% coinsurance, and Medical Supplies have a 9% coinsurance. Diabetic Supplies have a coinsurance between 9-10%, and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, with a copay between $0 and $100 for diagnostic procedures/tests, and no copay for lab services. Diagnostic radiological services have a copay up to $400, and therapeutic radiological services have a minimum 20% coinsurance, while outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice Giveback H5216-424 (PPO) plan with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by HumanaChoice Giveback H5216-424 (PPO), but specific services like Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, and Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services are not covered. There is a copay for the covered services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, the copay is $10, and for days 21-100, the copay is $214; additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Under the HumanaChoice Giveback H5216-424 (PPO) plan, acupuncture is covered with a $50 copay, and a limit of 20 treatments per year, but other services like over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and more are not covered. The meal benefit is covered with no copay.
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