Humana USAA Honor Giveback (PPO) - H5216-278-001

3.5 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

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

Plan ID: H5216-278-001

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

$0.00

Monthly Premium

Nebraska, South Dakota, Minnesota, Iowa, and North Dakota 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 Nebraska, South Dakota, Minnesota, Iowa, and North Dakota Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage	Details
Monthly plan premium	$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	-$1.00
Out-of-pocket maximum	$4,900.00
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 $15
Specialty doctor visit	In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $65
Inpatient hospital care	In-Network: Acute Hospital Services: $360 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services
Urgent care	Urgent Care: Copayment for Urgent Care $55 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125
Emergency room visit	Emergency Care: Copayment for Emergency Care $125 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 $125 Copayment for Worldwide Emergency Transportation $125
Ambulance transportation	In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $315 Air Ambulance: Coinsurance for Air Ambulance Services 20% Prior Authorization Required for Air Ambulance

Health Care Services and Medical Supplies

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

Coverage	Details
Chiropractic services	In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $20 Prior Authorization Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoring	In-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 $0
Durable medical equipment (DME)	Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 10%
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 $65 Copayment for Medicare-covered Lab Services $0 to $40 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services $50 OP Diag Proc & Tests - OPH$15 OP Diag Proc & Tests - PCP$65 OP Diag Proc & Tests - SPC$55 OP Diag Proc & Tests - UCC$50 Sleep Study (Fac Based) - OPH$65 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 $360 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $15 to $150
Home health care	Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 50%
Mental health inpatient care	In-Network: Psychiatric Hospital Services: $360 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient care	In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $60 Copayment for Medicare-covered Group Sessions $60
Outpatient services/surgery	In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $350 Prior Authorization Required for Outpatient Hospital Services $0 Diag Colonoscopy - OPH$50 Mental Health - OPH$350 Surgery Svcs - OPH$65 Wound Care - OPH Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $360 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $300 Prior Authorization Required for Ambulatory Surgical Center Services $0 Diag Colonoscopy - ASC$300 Surgery Svcs - ASC
Outpatient substance abuse care	In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $45 to $50 Copayment for Medicare-covered Group Sessions $45 to $50 Prior Authorization Required for Outpatient Substance Abuse Services $50 OP Substance Abuse Care - OPH$45 OP Substance Abuse Care - SPC
Over-the-counter items	In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0 Maximum plan benefit of $125 every three months for Over-The-Counter (OTC) Items Maximum Plan Benefit of $125 every three months
Podiatry services	In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $65 Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) care	In-Network: Skilled Nursing Facility Services: $10 per day for days 1 to 20 $203 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	Plan covers up to $4000 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. Any amount unused at the end of the year will expire. Your benefit can be used for most dental treatments such as: Preventive dental services, such as exams, routine cleanings, etc. Basic dental services, such as fillings, extractions, etc. Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges etc. 30% coinsurance applies to dentures. 30% - 40% coinsurance applies to bridges and crowns. Frequency limits may apply. Note: The allowance cannot be used on fluoride, cosmetic services and implants. Out of Network Plan covers up to $4000 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. Any amount unused at the end of the year will expire. Your benefit can be used for most dental treatments such as: Preventive dental services, such as exams, routine cleanings, etc. Basic dental services, such as fillings, extractions, etc. Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges etc. 30% coinsurance applies to dentures. 30% - 40% coinsurance applies to bridges and crowns. Frequency limits may apply. Note: The allowance cannot be used on fluoride, cosmetic services and implants. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Coverage

Details

Dental care

Plan covers up to $4000 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. Any amount unused at the end of the year will expire.
Your benefit can be used for most dental treatments such as:
Preventive dental services, such as exams, routine cleanings, etc.
Basic dental services, such as fillings, extractions, etc.
Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges etc.
30% coinsurance applies to dentures.
30% - 40% coinsurance applies to bridges and crowns.
Frequency limits may apply.
Note: The allowance cannot be used on fluoride, cosmetic services and implants.
Out of Network
Plan covers up to $4000 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. Any amount unused at the end of the year will expire.
Your benefit can be used for most dental treatments such as:
Preventive dental services, such as exams, routine cleanings, etc.
Basic dental services, such as fillings, extractions, etc.
Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges etc.
30% coinsurance applies to dentures.
30% - 40% coinsurance applies to bridges and crowns.
Frequency limits may apply.
Note: The allowance cannot be used on fluoride, cosmetic services and implants.
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 $65 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 $200 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.

Coverage

Details

Vision care

In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $65
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 $200 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	Out-of-Network: Medicare Covered Hearing Exams Services: Coinsurance 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.

Coverage	Details
Preventive services and health/wellness education programs	Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 Coinsurance for Medicare Covered Medicare-covered Preventive Services 50%

When reviewing Nebraska, South Dakota, Minnesota, Iowa, and North Dakota 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 Nebraska, South Dakota, Minnesota, Iowa, and North Dakota 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

Nebraska Counties Served

South Dakota Counties Served

Minnesota Counties Served

Iowa Counties Served

North Dakota 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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