HumanaChoice Giveback H5216-264 (PPO)

3.5 out of 5 stars

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Monthly Premium

HumanaChoice Giveback H5216-264 (PPO) is a PPO plan offered by Humana Inc.

Plan ID: H5216-264

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.

Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.

Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.

Learn more about Medicare Advantage plans such as HumanaChoice Giveback H5216-264 (PPO) - H5216-264 by Humana Inc. as well as other Medicare Advantage plans available in your area.

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Monthly Premium

Basic Costs and Coverage

Coverage	Cost
Monthly Deductible	$0
Out of Pocket Max	In-Network: $7925 Out-of-Network: 11000
Initial Coverage Limit	$0
Catastrophic Coverage Limit	$2100
Primary Care Doctor Visit	Out-of-Network: Doctor Office Visit Services: Coinsurance for Medicare Covered Primary Care Office Visit $30%
Specialty Doctor Visit	Out-of-Network: Doctor Specialty Visit Services: Coinsurance for Medicare Covered Physician Specialist Office Visit $30%
Inpatient Hospital Care	Out-of-Network: Acute Hospital Services: Coinsurance for Acute Hospital Services per Stay 50%
Urgent Care	Urgent Care: Copayment for Urgent Care $40 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $115
Emergency Room Visit	Emergency Care: Copayment for Emergency Care $115 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 $115 Copayment for Worldwide Emergency Transportation $115
Ambulance Transportation	In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $335 Air Ambulance: Coinsurance for Air Ambulance Services $20% Prior Authorization Required for Air Ambulance

Health Care Services and Medical Supplies

HumanaChoice Giveback H5216-264 (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	Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 30% In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 30%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring	In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Supplies 10% to 20% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10
Durable Medical Equipment (DME)	In-Network: Durable Medical Equipment: Copayment for Medicare-covered Durable Medical Equipment $0 Coinsurance for Medicare-covered Durable Medical Equipment 10% Prior Authorization Required for Durable Medical Equipment $0 Continuous Glucose Monitor - DME Prov$0 Continuous Glucose Monitor - Pharmacy10% DME - DME Prov10% DME - Pharmacy
Diagnostic Tests, Lab and Radiology Services, and X-Rays	Out-of-Network: Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30% to 50% Coinsurance for Medicare Covered Lab Services 50% Copayment for Medicare Covered Diagnostic Radiological Services $0 Coinsurance for Medicare Covered Diagnostic Radiological Services 50% Coinsurance for Medicare Covered Therapeutic Radiological Services 50% Coinsurance for Medicare Covered Outpatient X-Ray Services 30% to 50% $90 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$35 OP Diag Proc & Tests - SPC$40 OP Diag Proc & Tests - UCC$90 Sleep Study (Fac Based) - OPH$50 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home
Home Health Care	Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 50%
Mental Health Inpatient Care	Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 50%
Mental Health Outpatient Care	In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $30 Copayment for Medicare-covered Group Sessions $30
Outpatient Services / Surgery	Out-of-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 Coinsurance for Medicare Covered Outpatient Hospital Services 50% Copayment for Medicare Covered Ambulatory Surgical Center Services $0 Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50% $0 Diag Colonoscopy - OPH$35 Mental Health - OPH$360 Surgery Svcs - OPH$50 Wound Care - OPH
Outpatient Substance Abuse Care	In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $30 to $35 Copayment for Medicare-covered Group Sessions $30 to $35 Prior Authorization Required for Outpatient Substance Abuse Services $35 OP Substance Abuse Care - OPH$30 OP Substance Abuse Care - SPC Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 35% to 50% Coinsurance for Medicare Covered Group Sessions 35% to 50% $35 OP Substance Abuse Care - OPH$30 OP Substance Abuse Care - SPC Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 35% to 50% Coinsurance for Medicare Covered Group Sessions 35% to 50% $35 OP Substance Abuse Care - OPH$30 OP Substance Abuse Care - SPC In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $30 to $35 Copayment for Medicare-covered Group Sessions $30 to $35 Prior Authorization Required for Outpatient Substance Abuse Services $35 OP Substance Abuse Care - OPH$30 OP Substance Abuse Care - SPC
Over-the-counter (OTC) Items
Podiatry Services	In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $35 Prior Authorization Required for Podiatry Services Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 30% Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 30% In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $35 Prior Authorization Required for Podiatry Services
Skilled Nursing Facility Care	Out-of-Network: Skilled Nursing Facility Services: Coinsurance for Skilled Nursing Facility per Stay 50%

Dental Benefits

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

Coverage	Cost
Dental Care	$0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment, scaling for moderate inflammation up to 1 every 3 years. $0 copayment for bridge recementation, bridges-pontic, crown recementation, panoramic film or diagnostic x-rays up to 1 every 5 years. $0 copayment for bridges-crown up to 2 every 5 years. $0 copayment for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime. $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 emergency treatment for pain, oral surgery, 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 as needed with covered codes per year. $0 copayment for amalgam and/or composite filling, simple or surgical extraction up to unlimited per year. $2,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.

Coverage

Cost

Dental Care

$0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
$0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment, scaling for moderate inflammation up to 1 every 3 years.
$0 copayment for bridge recementation, bridges-pontic, crown recementation, panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for bridges-crown up to 2 every 5 years.
$0 copayment for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime.
$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 emergency treatment for pain, oral surgery, 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 as needed with covered codes per year.
$0 copayment for amalgam and/or composite filling, simple or surgical extraction up to unlimited per year.
$2,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.

Vision Benefits

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

Coverage	Cost
Vision Benefits	Out-of-Network: Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 30% to 35% Copayment for Medicare Covered Eyewear $0 $0 Diab Eye Exam - All POTs$35 Vision Svcs (MC) - SPC

Hearing Benefits

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

Coverage	Cost
Hearing Benefits	Out-of-Network: Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 30%

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	Out-of-Network: Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 Coinsurance for Medicare Covered Medicare-covered Preventive Services 35%

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