Humana USAA Honor Giveback (PPO)
Humana USAA Honor Giveback (PPO) H5216-221 Plan Details
Humana USAA Honor Giveback (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-221
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
Humana USAA Honor Giveback (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-221
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Humana USAA Honor Giveback (PPO) H5216-221 Plan Details
Humana USAA Honor Giveback (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-221
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
New Jersey Counties Served
Pennsylvania Counties Served
Elk
Somerset
Bedford
Jefferson
Clarion
Clearfield
Cameron
Huntingdon
Blair
Montgomery
Chester
Delaware
Philadelphia
Potter
Erie
Forest
Mckean
Venango
Mercer
Warren
Crawford
Northampton
Lehigh
Carbon
Schuylkill
Monroe
Luzerne
Lackawanna
Susquehanna
Wyoming
Beaver
Fayette
Sullivan
Westmoreland
Allegheny
Washington
Butler
Greene
Cambria
Armstrong
Fulton
Cumberland
Clinton
York
Lawrence
Juniata
Lycoming
Tioga
Bradford
Mifflin
Dauphin
Perry
Lebanon
Snyder
Adams
Berks
Lancaster
Wayne
Bucks
Montour
Union
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $6700 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $10 Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered Primary Care Office Visit $10 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $45 Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $45 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $425 per day for days 1 to 7 $0 per day for days 8 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: Acute Hospital Services: $425 per day for days 1 to 7 $0 per day for days 8 to 90 |
| Urgent Care | Copayment for Urgent Care $55 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125 |
| Emergency Room Visit | 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: Copayment for Air Ambulance Services $315 Prior Authorization Required for Air Ambulance Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $315 Copayment for Medicare Covered Ambulance Services - Air $315 |
Health Care Services and Medical Supplies
Humana USAA Honor Giveback (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Medicare Covered Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $20 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Supplies 10% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10 Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 10% Copayment for Medicare Covered Diabetic Therapeutic Shoes or Inserts $10 |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 18% Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 18% |
| 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 $55 Copayment for Medicare-covered Lab Services $0 to $55 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services $50 OP Diag Proc & Tests - OPH$10 OP Diag Proc & Tests - PCP$45 OP Diag Proc & Tests - SPC$55 OP Diag Proc & Tests - UCC$50 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 $10 to $105 Prior authorization required Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0 to $55 Copayment for Medicare Covered Lab Services $0 to $55 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 Outpatient X-Ray Services $10 to $105 $50 OP Diag Proc & Tests - OPH$10 OP Diag Proc & Tests - PCP$45 OP Diag Proc & Tests - SPC$55 OP Diag Proc & Tests - UCC$50 Sleep Study (Fac Based) - OPH$45 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 50% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $380 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Psychiatric Hospital Services: $380 per day for days 1 to 6 $0 per day for days 7 to 90 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 Out-of-Network: Medicare Covered Mental Health Services: Copayment for Medicare Covered Individual Sessions $40 Copayment for Medicare Covered Group Sessions $40 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $800 Prior Authorization Required for Outpatient Hospital Services $0 Diag Colonoscopy - OPH$85 Mental Health - OPH$800 Surgery Svcs - OPH$50 Wound Care - OPH Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $425 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $700 Prior Authorization Required for Ambulatory Surgical Center Services $0 Diag Colonoscopy - ASC$700 Surgery Svcs - ASC Prior authorization required Out-of-Network: Medicare Covered Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $800 Copayment for Medicare Covered Ambulatory Surgical Center Services $0 to $700 $0 Diag Colonoscopy - OPH$85 Mental Health - OPH$800 Surgery Svcs - OPH$50 Wound Care - OPH |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40 to $85 Copayment for Medicare-covered Group Sessions $40 to $85 Prior Authorization Required for Outpatient Substance Abuse Services $85 OP Substance Abuse Care - OPH$40 OP Substance Abuse Care - SPC Prior authorization required Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $40 to $85 Copayment for Medicare Covered Group Sessions $40 to $85 $85 OP Substance Abuse Care - OPH$40 OP Substance Abuse Care - SPC |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
|
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $45 Prior Authorization Required for Podiatry Services Prior authorization required Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $45 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $10 per day for days 1 to 20 $214 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: Skilled Nursing Facility Services: $10 per day for days 1 to 20 $214 per day for days 21 to 100 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| 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 from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $45 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0
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. Out-of-Network: Medicare Covered Eye Exams Services: Copayment for Medicare Covered Eye Exams $0 to $45 Copayment for Medicare Covered Eyewear $0 |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $45 Copayment for Routine Hearing Exams $0
Prior Authorization Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $499 to $799
Prior authorization required Out-of-Network: Medicare Covered Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $45 |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| 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:
Yearly "Wellness" visit Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
