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Humana USAA Honor Giveback with Rx (PPO) - H5216-305-000

3.5 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

Humana USAA Honor Giveback with Rx (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H5216-305-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

Michigan Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Michigan Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Enrollment may be limited to certain times of the year. See why you may be able to enroll.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$350.00
Out-of-pocket maximum$8,850.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visit
Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $0
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit Services:
Copayment for Medicare Covered Physician Specialist Office Visit $50
Inpatient hospital careIn-Network:

Acute Hospital Services:
$450 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services
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 transportationIn-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

Humana USAA Honor Giveback with Rx (PPO) covers a range of additional benefits. Learn more about Humana USAA Honor Giveback with Rx (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Prior Authorization Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoringIn-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:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $105
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20%
Copayment for Medicare-covered Lab Services $0 to $50
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
$105 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$50 OP Diag Proc & Tests - SPC$45 OP Diag Proc & Tests - UCC20% Sleep Study (Fac Based) - OPH$45 Sleep Study (Fac Based) - SPC$15 Sleep Study (Home Based) - Mbr's Home_

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $635
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 careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$450 per day for days 1 to 4
$0 per day for days 5 to 90
Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $45
Copayment for Medicare-covered Group Sessions $45
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $450
Prior Authorization Required for Outpatient Hospital Services
$0 Diag Colonoscopy - OPH$100 Mental Health - OPH$450 Surgery Svcs - OPH$45 Wound Care - OPH_

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $450
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $450
Prior Authorization Required for Ambulatory Surgical Center Services
$0 Diag Colonoscopy - ASC$450 Surgery Svcs - ASC_
Outpatient substance abuse careIn-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 servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $50
Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) careIn-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.

CoverageDetails
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 amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year.
$1,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.
Out of Network
$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 amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year.
$1,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.
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

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $50
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exam every year
Maximum Plan Benefit of $40 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 $300 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.

CoverageDetails
Hearing care
Out-of-Network:

Medicare Covered Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $50

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.

CoverageDetails
Preventive services and health/wellness education programsIn-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 Humana USAA Honor Giveback with Rx (PPO) offers prescription drug coverage, with an annual drug deductible of $350.00 (excludes Tiers 1 and 2)

    Coverage & Cost
    Coverage
    Cost
    Annual drug deductible$350.00 (excludes Tiers 1 and 2)
    Tier 1
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $10.00
    Tier 2
    • Standard retail $10.00
    • Preferred mail order $10.00
    • Standard mail order $20.00
    Annual drug deductible$350.00 (excludes Tiers 1 and 2)
    Tier 1
    • Standard retail N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    Tier 2
    • Standard retail N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    Annual drug deductible$350.00 (excludes Tiers 1 and 2)
    Tier 1
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $30.00
    Tier 2
    • Standard retail $30.00
    • Preferred mail order $0.00
    • Standard mail order $60.00

    When reviewing Michigan Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage 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 Michigan that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

    Plan Documents

    Links to plan documents

    Michigan Counties Served

    We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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