HumanaChoice Giveback H5216-154 (PPO)
Georgia Medicare Advantage Plan (2025 Plan)
Monthly Premium
Additional Coverage
Overall Government Star Rating
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Plan Overview
HumanaChoice Giveback H5216-154 (PPO) is a Medicare Advantage Plan With Part D Prescription Drug Coverage, which is available in Georgia and offered by the health insurance company Humana. This plan’s network type is PPO which determines in-network doctors who accept the health plan and whether a referral is needed.
Cost Summary
HumanaChoice Giveback H5216-154 (PPO) has a monthly premium cost of $0 per month, with an annual deductible of $1,000 annual deductible and a maximum out of pocket cost sharing of $14,000 In and Out-of-network $9,350 In-network. The most common benefit costs which people evaluate when choosing a plan are costs for a primary doctor visit, specialist doctor visit, emergency room visit, and ambulance. These costs are listed in this summary section and a full list of benefit costs for HumanaChoice Giveback H5216-154 (PPO) are defined below.
Additional Benefits and Coverage
HumanaChoice Giveback H5216-154 (PPO) is a Medicare Advantage plan which does include Medicare Part D Prescription Drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. HumanaChoice Giveback H5216-154 (PPO) includes coverage for hearing, vision, dental.
Medicare Advantage health plans can offer even more additional benefits. HumanaChoice Giveback H5216-154 (PPO) includes coverage for the following additional benefits:
Other benefits
Plan Benefits and Coverage Details
$9,350 In-network
Medical Benefits
Doctor Services
Out-of-network: 50% coinsurance per visit
Out-of-network: 50% coinsurance per visit
Tests, labs, & imaging
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Hospital Services
$0 per day for days 6 through 90
$0 per day for days 91 and beyond
Out-of-network: 50% per stay
Out-of-network: 50% coinsurance per visit
Skilled nursing facility
$214 per day for days 21 through 100
Out-of-network: 50% per stay
Preventive services
Out-of-network: $0 copay or 50% coinsurance
Ambulance
Out-of-network: $315 copay
Therapy services
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Mental health services
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Opioid treatment services
Other services
Out-of-network: 20% coinsurance per item
Out-of-network: 25% coinsurance per item
Out-of-network: 50% coinsurance per item
Prescription Drug Benefits
Tier drug costs for: Standard retail pharmacy drug cost for 1-month
| Tiers | Initial coverage phase | Catastrophic coverage phase |
|---|---|---|
| Preferred Generic | $5.00 copay | $0 copay |
| Generic | $15.00 copay | $0 copay |
| Preferred Brand | $47.00 copay | $0 copay |
| Non-Preferred Drug | 36% coinsurance | $0 copay |
| Specialty Tier | 28% coinsurance | $0 copay |
Part B Drugs
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Extra Benefits
Hearing
Out-of-network: 50% coinsurance
Out-of-network: $0 copay
Out-of-network: $699-999 copay
Preventive Dental
Out-of-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Comprehensive dental
Out-of-network: $0 copay
Vision
Out-of-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
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