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HumanaChoice Giveback H5216-138 (PPO)

Humana Inc.
HumanaChoice Giveback H5216-138 (PPO) H5216-138 Plan Details
3.5 out of 5 stars

HumanaChoice Giveback H5216-138 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-138

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

HumanaChoice Giveback H5216-138 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-138

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Humana Inc.
HumanaChoice Giveback H5216-138 (PPO) H5216-138 Plan Details
3.5 out of 5 stars

HumanaChoice Giveback H5216-138 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-138

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

Maine Counties Served

Franklin York Cumberland Sagadahoc Oxford Androscoggin Kennebec Lincoln Waldo Piscataquis Penobscot Hancock Washington Somerset Aroostook Knox

New Hampshire Counties Served

Rockingham Hillsborough Merrimack Belknap Oxford Strafford Cheshire

Connecticut Counties Served

Hartford Middlesex Litchfield Tolland New Haven

Massachusetts Counties Served

Essex Hampden Worcester Bristol Suffolk Dukes

Vermont Counties Served

Bennington Essex Windsor Orange Caledonia Windham

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $395
Out of Pocket Max In-Network: $5200
Out-of-Network: N/A
Initial Coverage Limit $2000
Catastrophic Coverage Limit $2,000
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $45
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $50
Out-of-Network:

Doctor Specialty Visit Services:
Copayment for Medicare Covered Physician Specialist Office Visit $65
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$445 per day for days 1 to 6
$0 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:

Acute Hospital Services:
$445 per day for days 1 to 7
$0 per day for days 8 to 90
Urgent Care
Copayment for Urgent Care $55

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $125
Emergency Room Visit
Copayment for Emergency Care $125
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $125
Copayment for Worldwide Emergency Transportation $125
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $315

Air Ambulance:
Copayment for Air Ambulance Services $315
Prior Authorization Required for Air Ambulance
Prior authorization required
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $315
Copayment for Medicare Covered Ambulance Services - Air $315

Health Care Services and Medical Supplies

HumanaChoice Giveback H5216-138 (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $15
Prior Authorization Required for Chiropractic Services
Prior authorization required
Out-of-Network:

Medicare Covered Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 40%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0
Coinsurance for Medicare-covered Diabetic Supplies 4% to 10%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0
Out-of-Network:

Medicare Covered Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 40%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 40%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 4%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Out-of-Network:

Medicare Covered Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 20%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $100
Copayment for Medicare-covered Lab Services $0 to $55
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
$100 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$50 OP Diag Proc & Tests - SPC$55 OP Diag Proc & Tests - UCC$100 Sleep Study (Fac Based) - OPH$50 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $50 to $400
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0 to $130
Prior authorization required
Out-of-Network:

Medicare Covered Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests
$45 to $65
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
40%
Copayment for Medicare Covered Lab Services
$45 to $65
Coinsurance for Medicare Covered Lab Services
40%
Copayment for Medicare Covered Diagnostic Radiological Services $65
Coinsurance for Medicare Covered Diagnostic Radiological Services 40%
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Copayment for Medicare Covered Outpatient X-Ray Services $45 to $65
Coinsurance for Medicare Covered Outpatient X-Ray Services 40%
$100 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$50 OP Diag Proc & Tests - SPC$55 OP Diag Proc & Tests - UCC$100 Sleep Study (Fac Based) - OPH$50 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Prior authorization required
Out-of-Network:

Medicare Covered Home Health Services:
Coinsurance for Medicare Covered Home Health 50%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$380 per day for days 1 to 6
$0 per day for days 7 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:

Psychiatric Hospital Services:
$380 per day for days 1 to 7
$0 per day for days 8 to 90
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $45
Copayment for Medicare-covered Group Sessions $45
Out-of-Network:

Medicare Covered Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 40%
Coinsurance for Medicare Covered Group Sessions 40%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $50 to $550
Prior Authorization Required for Outpatient Hospital Services
$450 Diag Colonoscopy - OPH$100 Mental Health - OPH$550 Surgery Svcs - OPH$50 Wound Care - OPH_

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $445
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $400 to $500
Prior Authorization Required for Ambulatory Surgical Center Services
$400 Diag Colonoscopy - ASC$500 Surgery Svcs - ASC_
Prior authorization required
Out-of-Network:

Medicare Covered Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 40%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40%
$450 Diag Colonoscopy - OPH$100 Mental Health - OPH$550 Surgery Svcs - OPH$50 Wound Care - OPH_
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $45 to $100
Copayment for Medicare-covered Group Sessions $45 to $100
Prior Authorization Required for Outpatient Substance Abuse Services
$100 OP Substance Abuse Care - OPH$45 OP Substance Abuse Care - SPC_
Prior authorization required
Out-of-Network:

Medicare Covered Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 40%
Coinsurance for Medicare Covered Group Sessions 40%
$100 OP Substance Abuse Care - OPH$45 OP Substance Abuse Care - SPC_
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $50
Prior Authorization Required for Podiatry Services
Prior authorization required
Out-of-Network:

Medicare Covered Podiatry Services:
Copayment for Medicare Covered Podiatry Services $65
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$10 per day for days 1 to 20
$214 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
$0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years.
$0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
$0 copayment for emergency diagnostic exam up to 1 per year.
$0 copayment for periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for necessary anesthesia with covered service up to unlimited per year.
Out of Network
$0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years.
$0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
$0 copayment for emergency diagnostic exam up to 1 per year.
$0 copayment for periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for necessary anesthesia with covered service up to unlimited per year.
Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $50
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exam every year
Maximum Plan Benefit of $75 every year

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0
  • Maximum 1 Pair every year
Copayment for Eyeglasses (lenses and frames) $0
  • Maximum 1 Pair every year
Maximum Plan Benefit of $100 every year
Members must use Humana's Medicare Insight Network, a national network of providers, which includes standard or PLUS providers. The allowance for the standard network is $50 less than the PLUS network.
Out-of-Network:

Medicare Covered Eye Exams Services:
Copayment for Medicare Covered Eye Exams $0 to $65
Copayment for Medicare Covered Eyewear $0

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $50
Copayment for Routine Hearing Exams $0
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $699 to $999
  • Maximum 2 Hearing Aids every year

Prior authorization required
Out-of-Network:

Medicare Covered Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $65

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
    • Tobacco use cessation
    Yearly "Wellness" visit
    Out-of-Network:

    Medicare Covered Medicare-covered Preventive Services:
    Copayment for Medicare Covered Medicare-covered Preventive Services $0

    Prescription Drug Costs and Coverage

    The HumanaChoice Giveback H5216-138 (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $395 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $395 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard mail order $10.00
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    Generic
    • Standard mail order $20.00
    • Standard retail $5.00
    • Preferred cost-share mail order $5.00
    Annual Drug Deductible $395 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard mail order N/A
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    Generic
    • Standard mail order N/A
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    Annual Drug Deductible $395 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard mail order $30.00
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    Generic
    • Standard mail order $60.00
    • Standard retail $15.00
    • Preferred cost-share mail order $0.00
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