HumanaChoice Giveback H5216-345 (PPO) 

Humana Inc. HumanaChoice Giveback H5216-345 (PPO) is Medicare Advantage plan available in both Georgia and South Carolina and has a star rating of 3.5 for the 2025 plan year.

Plan Costs and Coverage

Monthly premium	$0.00. (You are still responsible for your part B premium)
Vision coverage	Yes
Dental coverage	Yes
Hearing coverage	Yes
Prescription drugs	Yes, and your part d premium is included in the plan which is $0 per month.
Medical deductible	$450.00
Out-of-pocket maximum	$9,350.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$2,000.00
Primary care doctor visit	In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0
Specialty doctor visit	Out-of-Network: Doctor Specialty Visit Services: Coinsurance for Medicare Covered Physician Specialist Office Visit 50%
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 $45 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $110
Emergency room visit	Emergency Care: Copayment for Emergency Care $110 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 $110 Copayment for Worldwide Emergency Transportation $110
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

Health Care Services and Medical Supplies

HumanaChoice Giveback H5216-345 (PPO) covers a range of additional benefits. Learn more about HumanaChoice Giveback H5216-345 (PPO) benefits, some of which may not be covered by Original Medicare Part A and Medicare Part B.

Coverage	Details
Chiropractic services	In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoring	Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 50% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 50%
Durable medical equipment (DME)	In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 4% Prior Authorization Required for Durable Medical Equipment
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 $120 Copayment for Medicare-covered Lab Services $0 to $50 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services $15 Coumadin Clinic Svcs – OPH$120 OP Diag Proc & Tests – OPH$0 OP Diag Proc & Tests – PCP$45 OP Diag Proc & Tests – SPC$45 OP Diag Proc & Tests – UCC$100 Sleep Study (Fac Based) – OPH$45 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 $0 to $325 Copayment for Medicare-covered Therapeutic Radiological Services $45 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 to $130
Home health care	In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services
Mental health inpatient care	Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 50%
Mental health outpatient care	Out-of-Network: Medicare Covered Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50%
Outpatient services/surgery	Out-of-Network: Medicare Covered Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 50% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50% $0 Diag Colonoscopy – OPH$100 Mental Health – OPH$450 Surgery Svcs – OPH$45 Wound Care – OPH_
Outpatient substance abuse care	In-Network: Outpatient Substance Abuse Services: 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_
Podiatry services	In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $45 Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) care	In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage

Details

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, though there may be provider network restrictions. See the plan Evidence of Coverage

Coverage

Details

Vision care

In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $45 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 $150 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.

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Hearing care	In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $45 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

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage

Details

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

Prescription Drug Costs and Coverage

The HumanaChoice Giveback H5216-345 (PPO) offers prescription drug coverage, with an annual drug deductible of $450.00 (excludes Tiers 1 and 2)

Coverage	Cost 30 day supply 60 day supply 90 day supply
Annual drug deductible	$450.00 (excludes Tier 1 and 2)
Tier 1	Standard retail $0.00 Preferred mail order $0.00 Standard mail order $10.00
Tier 2	Standard retail $5.00 Preferred mail order $5.00 Standard mail order $20.00

When reviewing South Carolina and Georgia Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage health plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of South Carolina and Georgia that offer similar benefits at similar or lower prices than the plan above. Call 1-833-567-3163 to speak with a licensed insurance agent who can help you compare plans.

Enrolling in H5216-345 Medicare Advantage Plans in Georgia and South Carolina

Medicare beneficiaries from Georgia and South Carolina may have enrollment access to Medicare Advantage plans from Humana and other insurance companies.

Get help comparing your local plan options by calling to speak with a licensed insurance agent who can help you find out if your doctor and prescription drugs are covered by a Medicare Advantage plan in your area.