HumanaChoice Giveback H5216-154 (PPO)
Monthly premium
$0.00
CMS Plan Rating
Contract ID
★★★
★
★
H5216-154-000
Medical deductible
$350
Rx deductible
$400 (Tiers 3-5)
Medicare Part B Giveback
$64.00
Monthly premium
$0.00
HumanaChoice Giveback H5216-154 (PPO)
Contract ID
CMS Plan Rating
H5216-154-000
★★★
★
★
Medical deductible
$350
Rx deductible
$400 (Tiers 3-5)
Medicare Part B Giveback
$64.00
Medicare Advantage, also known as Medicare Part C, is a health plan option that provides Medicare Part A and Part B coverage. Medicare Advantage plans are offered by private insurance companies that are approved by Medicare. These plans provide benefits similar to Original Medicare Part A and Part B, but often include additional benefits such as dental, hearing and vision.
Medical benefits
In-network
What you pay
Primary doctor
$20 copay
Specialist
$55 copay
Outpatient diagnostic tests/Lab and X-Rays
$0 - $325 copay
Urgent care
$45 copay
Maximum Out-of-Pocket (Annually)
$9,350
Ambulance services
$315 copay
Emergency room (waived if admitted to hospital within 24 hours)
$110 copay
Inpatient hospital care
$435 per day (Days 1-5)
Skilled nursing facility
$0 copay per day (Days 1-20)
- Important Notice
For full plan details, see the Evidence of Coverage or Summary of Benefits in the Plan Documents.
Rx benefits
Tier 1 - Preferred generic
$5 copay
Tier 2 - Generic
$15 copay
Tier 3 - Preferred brand
$47 copay
Tier 4 - Non-preferred brand
36%
Tier 5 - Specialty
28%
Additional Benefits
- Vision
- Dental
- Hearing
- SilverSneakers Gym Membership
- Worldwide Emergency Coverage