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HumanaChoice Giveback H5216-264 (PPO)

Health Insurance Company: Humana

Medicare Advantage Plan Details

Humana
$0 /mo
monthly premium
HumanaChoice Giveback H5216-264 (PPO)
Additional Coverage
Overall Star Rating (2025)
  • Rx
  • Dental
  • Vision
  • Hearing
3.5
out of 5 stars

General Plan Details

Medical Deductible
$375
Out-of-Pocket Maximum
$7925
Rx Drug Coverage
Yes
Rx Deductible
$590
Primary Doctor Office Visit
$10 copay per visit
Specialist Office Visit
$50 copay per visit

Additional Benefits

Dental Coverage
Yes
Vision Coverage
Yes
Mental Health Coverage
Yes
Transportation for non-emergency
No
Fitness Benefits
No
Worldwide emergency
Yes
Telehealth
Yes
Part B Give Back
No

Doctor & Hospital Coverage

Primary Doctor Office Visit
In-network: $10 copay per visit
Out-of-network: 50% coinsurance per visit
Specialist Office Visit
In-network: $50 copay per visit
Out-of-network: 50% coinsurance per visit
Periodic Exam Coverage
In-network: $0 copay
Out-of-network: $0 copay or 50% coinsurance

Emergency Room

$110 copay per visit (always covered)

Ambulance Coverage

In-network: $315 copay
Out-of-network: $315 copay

Lab, X-Ray, Radiology Coverage

Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: In-network: $0-90 copay
Out-of-network: 50% coinsurance
Medicare-covered lab services: In-network: $0-55 copay
Out-of-network: 50% coinsurance
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): In-network: $0-360 copay
Out-of-network: 50% coinsurance
Medicare-covered x-ray services: In-network: $10-130 copay
Out-of-network: 50% coinsurance

Outpatient Surgery Coverage

Outpatient hospital:
Medicare-covered outpatient hospital services: In-network: $0-360 copay per visit
Out-of-network: 50% coinsurance per visit

Hospitalization Coverage

Inpatient hospital-acute:
In-network: $360 per day for days 1 through 6
$0 per day for days 7 through 90
$0 per day for days 91 and beyond
Out-of-network: 50% per stay
Inpatient hospital psychiatric:
In-network: $318 per day for days 1 through 6
$0 per day for days 7 through 90
Out-of-network: 50% per stay

Rehabilitation Coverage

Occupational therapy services:
In-network: $35 copay
Out-of-network: 50% coinsurance
Physical therapy and speech and language therapy services:
In-network: $35 copay
Out-of-network: 50% coinsurance

Urgent Care Coverage

$45 copay per visit (always covered)

Skilled Nursing Facility (SNF)

In-network: $0 per day for days 1 through 20
$214 per day for days 21 through 100
Out-of-network: 50% per stay

Mental Health Coverage

Medicare-covered individual sessions: In-network: $10 copay
Out-of-network: 50% coinsurance
Medicare-covered group sessions: In-network: $10 copay
Out-of-network: 50% coinsurance

Dental, Vision, Hearing Benefits

Dental Services

Oral exams:
In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays:
In-network: $0 copay
Out-of-network: $0 copay

Vision Benefits

Eye exams:
Routine eye exams: In-network: $0 copay
Out-of-network: $0 copay
Eyewear:
Contact Lenses: In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses: In-network: $0 copay
Out-of-network: $0 copay

Hearing Benefits

Hearing exams:
Routine hearing exams: In-network: $50 copay
Out-of-network: 50% coinsurance
Hearing aids:
Hearing aids (all types): In-network: $699-999 copay
Out-of-network: $699-999 copay

Rx Drug Coverage - Standard Retail Cost

Tier 1: Preferred Generic

$5.00 copay (30-day supply)
$15.00 copay (90-day supply)

Tier 2: Generic

$8.00 copay (30-day supply)
$24.00 copay (90-day supply)

Tier 3: Preferred Brand

$47.00 copay (30-day supply)
$141.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

47% coinsurance (30-day supply)
47% coinsurance (90-day supply)

Tier 5: Specialty Tier

25% coinsurance (30-day supply)

Tier 1: Preferred Generic

$10.00 copay (30-day supply)
$30.00 copay (90-day supply)

Tier 2: Generic

$20.00 copay (30-day supply)
$60.00 copay (90-day supply)

Tier 3: Preferred Brand

$47.00 copay (30-day supply)
$141.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

47% coinsurance (30-day supply)
47% coinsurance (90-day supply)

Tier 5: Specialty Tier

25% coinsurance (30-day supply)

Tier 1: Preferred Generic

$5.00 copay (30-day supply)
$0.00 copay (90-day supply)

Tier 2: Generic

$8.00 copay (30-day supply)
$0.00 copay (90-day supply)

Tier 3: Preferred Brand

$47.00 copay (30-day supply)
$131.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

47% coinsurance (30-day supply)
47% coinsurance (90-day supply)

Tier 5: Specialty Tier

25% coinsurance (30-day supply)

More Additional Benefits

Annual physical exams
Yes
Chiropractic Coverage
No
Acupuncture
Yes
Massage Therapy
No
Health Education
No
Counseling Services
No
Support for Caregivers of Enrollees
No
Personal Emergency Response System (PERS)
No
In-home support services
No
Home and bathroom safety devices
No
Meals for short duration
Yes

Plan Links

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Where This Plan is Available

Additional Plan Info

Plan Year:
2025
Insurance Company Website:
Humana

Health Insurance Companies Offering Plans

Medicare Advantage and Part D plans and benefits offered by the following insurance companies:

  • Aetna Medicare
  • Anthem Blue Cross Blue Shield
  • Anthem Blue Cross
  • Anthem Blue Cross and Blue Shield
  • Aspire Health Plan
  • Baylor Scott & White Health Plan
  • Capital Blue Cross
  • Cigna Healthcare
  • Dean Health Plan
  • Devoted Health
  • Florida Blue Medicare
  • Freedom Health
  • GlobalHealth
  • Health Care Service Corporation
  • Healthy Blue
  • HealthSun
  • Humana
  • Molina Healthcare
  • Mutual of Omaha
  • Medica Central Health Plan
  • Optimum HealthCare
  • Premera Blue Cross
  • SCAN Health Plan
  • Simply
  • UnitedHealthcareⓇ
  • Wellcare
  • WellPoint