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2025 Medicare Advantage Plan Benefit Details for the humanachoice giveback h5216-430 (ppo)
2025 Medicare Advantage Plan Details
Medicare Plan Name:HumanaChoice Giveback H5216-430 (PPO)
Location:Juab, Utah     Click to see other locations
Plan ID:H5216 - 430 - 0     Click to see other plans
Member Services:(800)457-4708 TTY users 711
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the HumanaChoice Giveback H5216-430 (PPO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Medicare Part B Premium Reduction:This plan has a $72.00 Part B monthly premium rebate (or giveback). However, you must continue to pay your Medicare Part B premium.
Annual Rx Deductible:$350 (Tier 1 and 2 excluded from the Deductible.)
Health Plan Type:PPO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$4,995
Drug Benefit Type ❔Enhanced Alternative (EA)
Total Number of Formulary Drugs:3,365 drugsBrowse the HumanaChoice Giveback H5216-430 (PPO) Formulary
Formulary Exception Tier:Tier 4 If your formulary exception request is approved, your drug will be placed on this tier.
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. 
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$0.00$20.00$47.0043%28%
• Number of Drugs per
  Tier:		409521823941671
Plan's Pharmacy Search:https://www.humana.com/pharmacy/
Plan Offers Mail Order?Yes
Medicare Plan Pharmacy Numbers: BIN: 015581   PCN: 03200000   See BIN/PCNs for all plans
Medicare Prescription Payment Plan   (M3P) Pharmacy Numbers: M3P BIN: 610649   M3P PCN: MPPP7777   See M3P BIN/PCNs for all plans
Number of Members enrolled in this plan in Juab, Utah:33 members
Number of Members enrolled in this plan in (H5216 - 430):1,537 members
Plan’s Summary Star Rating: 3.5 out of 5 Stars.
• Customer Service Rating: 4 out of 5 Stars.
• Member Experience Rating: 4 out of 5 Stars.
• Drug Cost Accuracy Rating: 3 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔
Total
Premium		Part C
Premium		Part D Basic
Premium		Part D Supplemental
Premium
$0.00$0.00$0.00$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ $0.00
Total Monthly Premium with LIS (Parts C & D): $0.00
— Plan Health Benefits —
** Base Plan **
Premium
• Total monthly premium: $0.00
• Health plan premium: $0.00
• Drug plan premium: $0.00
• You must continue to pay your Part B premium.
• Part B premium reduction: $72.00
Deductible
• Health plan deductible: $495 Annual Deductible
• Other health plan deductible: Out-of-network: No
• Drug plan deductible: $350.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $4,995 In-network
• $8,950 In and Out-network
Doctor visits
• Primary: In-network: $0 copay
• Primary: Out-of-network: 50% coinsurance per visit
• Specialist: In-network: $50 copay
• Specialist: Out-of-network: Not covered
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: In-network: $0-$55 copay (authorization required)
• Diagnostic tests and procedures: Out-of-network: 50% coinsurance
• Lab services: In-network: $0-$55 copay (authorization required)
• Lab services: Out-of-network: 50% coinsurance
• Diagnostic radiology services (e.g., MRI): In-network: $0-$450 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): Out-of-network: 50% coinsurance
• Outpatient x-rays: In-network: $0-$150 copay (authorization required)
• Outpatient x-rays: Out-of-network: 50% coinsurance
Inpatient hospital coverage
• In-network: $275 per day for days 1 through 6
$0 per day for days 7 through 90
$0 per day for days 91 and beyond (authorization required)
• Out-of-network: 50% per stay (authorization required)
Outpatient hospital coverage
• In-network: $0-$450 copay per visit (authorization required)
• Out-of-network: Not covered
Skilled Nursing Facility
• In-network: $10 copay per day for days 1 through 20
$214 copay per day for days 21 through 65
$0 copay per day for days 66 through 100 (authorization required)
• Out-of-network: 50% per stay (authorization required)
Preventive care
• In-network: $0 copay
• Out-of-network: Not covered
Ground ambulance
• In-network: $315 copay
• Out-of-network: $315 copay
Rehabilitation services
• Occupational therapy visit: In-network: $40 copay (authorization required)
• Occupational therapy visit: Out-of-network: Not covered
• Physical therapy and speech and language therapy visit: In-network: $40 copay (authorization required)
• Physical therapy and speech and language therapy visit: Out-of-network: Not covered
Mental health services
• Inpatient hospital - psychiatric: In-network: $275 per day for days 1 through 6
$0 per day for days 7 through 90 (authorization required)
• Inpatient hospital - psychiatric: Out-of-network: 50% per stay (authorization required)
• Outpatient group therapy visit with a psychiatrist: In-network: $0 copay (authorization required)
• Outpatient group therapy visit with a psychiatrist: Out-of-network: Not covered
• Outpatient individual therapy visit with a psychiatrist: In-network: $0 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist: Out-of-network: Not covered
• Outpatient group therapy visit: In-network: $0 copay (authorization required)
• Outpatient group therapy visit: Out-of-network: Not covered
• Outpatient individual therapy visit: In-network: $0 copay (authorization required)
• Outpatient individual therapy visit: Out-of-network: Not covered
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): In-network: 5% coinsurance per item (authorization required)
• Durable medical equipment (e.g., wheelchairs, oxygen): Out-of-network: Not covered
• Prosthetics (e.g., braces, artificial limbs): In-network: 5% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): Out-of-network: Not covered
• Diabetes supplies: In-network: $0 copay or 10%-20% coinsurance per item (authorization required)
• Diabetes supplies: Out-of-network: Not covered
Hearing
• Hearing exam: In-network: $50 copay (authorization required)
• Hearing exam: Out-of-network: Not covered
• Fitting/evaluation: In-network: $0 copay (authorization required)
• Fitting/evaluation: Out-of-network: MC: Not covered NMC: $0 copay
• Hearing aids: In-network: $699-$999 copay (limits apply)
• Hearing aids: Out-of-network: $699-$999 copay
• Hearing aids - inner ear: In-network: Not covered
• Hearing aids - inner ear: Out-of-network: Not covered
• Hearing aids - outer ear: In-network: Not covered
• Hearing aids - outer ear: Out-of-network: Not covered
• Hearing aids - over the ear: In-network: Not covered
• Hearing aids - over the ear: Out-of-network: Not covered
• Hearing aids - over the counter (OTC): In-network: Not covered
• Hearing aids - over the counter (OTC): Out-of-network: Not covered
Medicare covered dental services
• In-network: $50 copay (authorization required)
• Out-of-network: Not covered
Preventive dental
• Office visit: In-network: Coming soon
• Oral exam: In-network: $0 copay (limits apply)
• Oral exam: Out-of-network: $0 copay
• Cleaning: In-network: $0 copay (limits apply)
• Cleaning: Out-of-network: $0 copay
• Fluoride treatment: In-network: Not covered
• Fluoride treatment: Out-of-network: Not covered
• Dental x-ray(s): In-network: $0 copay (limits apply)
• Dental x-ray(s): Out-of-network: $0 copay per x-ray
• Other diagnostic dental services: In-network: $0 copay (limits apply)
• Other diagnostic dental services: Out-of-network: $0 copay
• Other preventive dental services: In-network: $0 copay (limits apply)
• Other preventive dental services: Out-of-network: $0 copay
Comprehensive dental
• Restorative services: In-network: Not covered
• Restorative services: Out-of-network: Not covered
• Endodontics: In-network: Not covered
• Endodontics: Out-of-network: Not covered
• Periodontics: In-network: Not covered
• Periodontics: Out-of-network: Not covered
• Prosthodontics, removable: In-network: Not covered
• Prosthodontics, removable: Out-of-network: Not covered
• Prosthodontics, fixed: In-network: Not covered
• Prosthodontics, fixed: Out-of-network: Not covered
• Maxillofacial Prosthetics: In-network: Not covered
• Maxillofacial Prosthetics: Out-of-network: Not covered
• Oral and Maxillofacial Surgery: In-network: Not covered
• Oral and Maxillofacial Surgery: Out-of-network: Not covered
• Implant Services: In-network: Not covered
• Implant Services: Out-of-network: Not covered
• Orthodontics: In-network: Not covered
• Orthodontics: Out-of-network: Not covered
• Adjunctive General Services: In-network: $0 copay (authorization required)
• Adjunctive General Services: Out-of-network: $0 copay
Vision
• Routine eye exam: In-network: MC: $0-$50 copay NMC: $0 copay (limits apply, authorization required)
• Routine eye exam: Out-of-network: Not covered
• Other: In-network: Not covered
• Other: Out-of-network: Not covered
• Contact lenses: In-network: $0 copay (limits apply, authorization required)
• Contact lenses: Out-of-network: $0 copay (limits apply)
• Eyeglasses (frames and lenses): In-network: $0 copay (limits apply, authorization required)
• Eyeglasses (frames and lenses): Out-of-network: $0 copay (limits apply)
• Eyeglass frames: In-network: Not covered
• Eyeglass frames: Out-of-network: Not covered
• Eyeglass lenses: In-network: Not covered
• Eyeglass lenses: Out-of-network: Not covered
• Upgrades: In-network: Not covered
• Upgrades: Out-of-network: Not covered
Medically-approved non-opioid pain management services
• Chiropractic services: MC: $20 copay NMC: Not covered (authorization required)
• Acupuncture: Some coverage
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Transportation services: Not covered
• Over-the-counter drug benefits: Not covered
• Meals for short duration: Some coverage
• Annual physical exams: Some coverage
• Telehealth: Some coverage
• WorldWide emergency transportation: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Not covered
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Not covered
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Not covered
• Counseling Services: Not covered
Transportation
• In-network: Not covered
Foot care (podiatry services)
• Foot exams and treatment: In-network: MC: $50 copay (authorization required)
• Foot exams and treatment: Out-of-network: Not covered
• Routine foot care: In-network: Not covered
Medicare Part B drugs
• Part B Insulin drugs: In-network: 0%-20% coinsurance (up to $35) (authorization required)
• Part B Insulin drugs: Out-of-network: 50% coinsurance
• Chemotherapy: In-network: 0%-20% coinsurance (authorization required)
• Chemotherapy: Out-of-network: 50% coinsurance
• Other Part B drugs: In-network: 0%-20% coinsurance (authorization required)
• Other Part B drugs: Out-of-network: 50% coinsurance




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