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Humana Essentials Plus Giveback H5216-435 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Humana Essentials Plus Giveback H5216-435 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Humana Essentials Plus Giveback H5216-435 (PPO) in 2026, please refer to our full plan details page.
Humana Essentials Plus Giveback H5216-435 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in AZ, CO, NM. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Humana Essentials Plus Giveback H5216-435 (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 Humana Essentials Plus Giveback H5216-435 (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 Humana Essentials Plus Giveback H5216-435 (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 $74.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $900.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $13900.00 (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 $13900.00 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 Humana Essentials Plus Giveback H5216-435 (PPO) plan offers an Enhanced Alternative drug benefit with no prescription drug deductible. During the initial coverage phase, you will pay no copay for Tier 1 preferred generic drugs at standard pharmacies and preferred mail, or a $20 copay through standard mail. For Tier 2 standard generics, the copay is $30 at standard pharmacies and preferred mail, while Tier 3 preferred brands and Tier 4 non-preferred drugs require 35% and 33% coinsurance respectively. After your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for Medicare Part D covered drugs. Additionally, beneficiaries who qualify for the Extra Help low-income subsidy will pay $0 for their Part D drugs. This plan provides a predictable cost structure to help you manage your healthcare budget effectively.
Additional Benefits
The Humana Essentials Plus Giveback H5216-435 (PPO) plan offers comprehensive coverage for essential medical services, featuring no copays for primary care doctor visits and annual preventive exams. For inpatient hospital stays, members pay a daily copay of $370 for the first five days and no copay for additional days, while emergency room visits carry a $115 copay. Outpatient hospital services and diagnostic lab tests generally require a 20% coinsurance, alongside variable copays. This PPO plan also includes valuable dental, vision, and hearing benefits to help minimize your out-of-pocket costs. Routine dental cleanings and vision exams are covered with no copays, and the plan provides a $750 annual maximum benefit for dental care. Furthermore, home health services require no copay, and skilled nursing care is covered with no copay for the first 20 days of your stay.
Inpatient Hospital See details
Humana Essentials Plus Giveback H5216-435 (PPO) covers inpatient acute and psychiatric hospital stays with a $370 daily copay for days 1 to 5, no copay for days 6 and beyond, and no coinsurance. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional inpatient psychiatric days are not covered.
Outpatient Services See details
Humana Essentials Plus Giveback H5216-435 (PPO) covers outpatient hospital services with a $0 to $50 copay and 20% coinsurance, and ambulatory surgical center services with no copay and 20% coinsurance. Patients will also pay a $370 copay with no coinsurance for observation services, a $25 to $35 copay with no coinsurance for outpatient substance abuse services, and no copay or coinsurance for outpatient blood services.
Partial Hospitalization See details
Partial hospitalization benefits are covered by the Humana Essentials Plus Giveback H5216-435 (PPO) plan with a $35 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Humana Essentials Plus Giveback H5216-435 (PPO) partially covers ambulance and transportation services, featuring a $335 copay for ground ambulance services and a $1,250 copay for air ambulance services, both with no coinsurance. Non-emergency transportation services to plan-approved or health-related locations are not covered.
Emergency Services See details
Humana Essentials Plus Giveback H5216-435 (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $115 copay and no coinsurance.
Primary Care See details
Humana Essentials Plus Giveback H5216-435 (PPO) covers primary care physician visits with no copay and no coinsurance, while specialist visits require a $45 copay and no coinsurance. Physical, occupational, and speech therapy services require a 20% coinsurance and no copay, whereas chiropractic services are partially covered with a $15 copay and no coinsurance because routine chiropractic care is not covered.
Preventive Services See details
Humana Essentials Plus Giveback H5216-435 (PPO) partially covers preventive services, offering covered benefits like annual physical exams, glaucoma screenings, and memory fitness with no copay or coinsurance. However, several sub-services are not covered, including health education, weight management, in-home safety assessments, alternative therapies, and personal emergency response systems.
Hearing Services See details
Humana Essentials Plus Giveback H5216-435 (PPO) partially covers hearing services, offering Medicare-covered exams for a $45 copay, routine exams and fittings with no copay, and up to two prescription hearing aids per year for a $499 to $1,099 copay, with no coinsurance or deductibles. OTC hearing aids, as well as inner ear, outer ear, and over-the-ear prescription hearing aids, are not covered.
Vision Services See details
Humana Essentials Plus Giveback H5216-435 (PPO) partially covers vision services, offering eye exams with a $0 to $45 copay and covered eyewear with no copay, though standalone frames, lenses, and upgrades are not covered. This benefit features no deductibles or coinsurance, requires prior authorization, and includes annual maximum limits of $75 for exams and $150 for eyewear.
Dental Services See details
Dental services are partially covered by Humana Essentials Plus Giveback H5216-435 (PPO), which offers a $750 annual maximum benefit for both in-network and out-of-network care. Medicare-covered dental services require a $45 copay and no coinsurance, while covered preventive and comprehensive services, such as cleanings, exams, and x-rays, have no copay and no coinsurance. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Humana Essentials Plus Giveback H5216-435 (PPO) covers home infusion bundled services, which require prior authorization and step therapy. Covered Part B insulin drugs require a $35 copay and coinsurance ranging from no coinsurance up to 20%, while chemotherapy and other Part B drugs feature no copay and coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Dialysis Services are covered by Humana Essentials Plus Giveback H5216-435 (PPO) with a 20% coinsurance and no copay. Prior authorization is required to receive these covered services.
Medical Equipment See details
Humana Essentials Plus Giveback H5216-435 (PPO) covers durable medical equipment (DME) with a 15% coinsurance and no copay, and diabetic supplies with a 10% to 20% coinsurance and no copay. Diabetic therapeutic shoes require a $10 copay, and prosthetics and medical supplies carry a 15% to 20% coinsurance; prior authorization is required for these services.
Diagnostic and Radiological Services See details
Humana Essentials Plus Giveback H5216-435 (PPO) covers diagnostic and radiological services, with lab and outpatient X-ray services requiring a 20% coinsurance and no copay. Diagnostic procedures cost a 20% coinsurance and a $0 to $50 copay, while diagnostic radiological services have a $0 to $300 copay, and therapeutic radiological services require a 20% coinsurance and a $50 copay.
Home Health Services See details
Home health services are covered by Humana Essentials Plus Giveback H5216-435 (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Humana Essentials Plus Giveback H5216-435 (PPO) does not cover Cardiac Rehabilitation Services in practice, as all sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are not covered. Because there is no coverage for these services, there are no copays or coinsurance, and you will be responsible for the entire cost of care.
Skilled Nursing Facility (SNF) See details
Humana Essentials Plus Giveback H5216-435 (PPO) partially covers Skilled Nursing Facility (SNF) services with prior authorization, though additional days beyond Medicare-covered limits are not covered. There is no copay or coinsurance for days 1 through 20, followed by a $218 daily copay and no coinsurance for days 21 through 100.
Other Services See details
Other Services are partially covered by Humana Essentials Plus Giveback H5216-435 (PPO), which offers acupuncture benefits with a $45 copay and no coinsurance for up to 20 treatments per year. Over-the-counter (OTC) items, meal benefits, and Dual Eligible SNPs with Highly Integrated Services are not covered.
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