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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

We're Here to Help You Enroll

Or Call for Live Support from Licensed Insurance Agents

(888) 311-4264
TTY 711

Mon-Fri: 8am-9pm, Sat: 8am-8pm ETNo Obligation to Enroll

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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TTY 711
Mon-Fri: 8am-9pm, Sat: 8am-8pm ET
No Obligation to Enroll

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Where This Plan is Available

State:
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Additional Plan Info

Plan Year:
2025
Insurance Company Website:
Humana
General Disclaimer   
  • Estimated annual savings is determined by subtracting a plan's annual cost estimate of the medications entered from the medications' average retail prices. The annual cost estimate for a plan includes covered annual monthly premiums and any annual cost sharing expenses that you must pay out-of-pocket for the medications entered. This number can only be calculated if the consumer enters medication information.
  • The savings number is calculated from all of the saved sessions where another consumer entered medication information and their current plan. For each saved session, we calculate the cost of each plan based on the medication entered and geographical location. The savings number is derived by comparing the cost of the plan to the cheapest plan in that geographical location and taking the average.
  • The retail drug cost is an estimated amount based on the out-of-pocket expenses you may expect to pay in a calendar year for medications that are not covered by an insurance plan's formulary on estimated retail drug price (retail drug cost is based on national averages for a medication and assumes adherence).
  • If you need help, please call 1-888-296-0117 (TTY User: 711) Mon - Fri, 8am - 9pm ET for Customer Service Representatives and licensed insurance agents who can assist with finding information on available Medicare Advantage, Medicare Supplement Insurance and Prescription Drug Plans.
  • For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • You must have both Part A and B to enroll in a Medicare Advantage plan. Members may enroll in the plan only during specific times of the year. Contact the plan for more information.
  • You must have Medicare Part A or Part B (or both) to join a Medicare Prescription Drug plan. Members may enroll in the plan only during specific times of the year. Contact the plan for more information.
  • For plans with Part D Coverage: You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778 or consult www.socialsecurity.gov; or your Medicaid Office.
  • Every year, Medicare evaluates plans based on a 5-star rating system.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days a week or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696 (or equivalent written notice).
  • Other Pharmacies, Physicians, and Providers are available in the network.
  • Pharmacies, Physicians, and Providers may also contract with other Plan Sponsors.
  • Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call the Plan’s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
  • The purpose of this communication is the solicitation of insurance. Contact may be made by an insurance agent/producer or insurance company. For Medicare Supplement Insurance Only: Open enrollment lasts 6 months and begins the first day of the month in which you are 65 or older and enrolled in Medicare Part B. Some states have an open enrollment period for eligible individuals under the age of 65, and a second enrollment period when they turn 65. If you are under 65, check with your state insurance department for guidelines.
  • Under a contractual relationship between our insurance agency partners and each insurance company issuing a policy offered by our agency partners, our agency partners earn a commission paid by the insurance company for each policy the agency partner sells. The commission rate varies by policy and may increase as the agency partner sells more policies. In some cases, our agency partners may earn bonus commission amounts based on criteria such as the number of policies sold.
  • Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
  • Partner Disclosure: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week to get information on all of your options.
Low-Income Subsidy   

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