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Humana USAA Honor Giveback with Rx (PPO) - H5525-057-000

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: H5525-057-000

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

$0.00

Monthly Premium

California 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 California 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

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$350.00
Out-of-pocket maximum$6,100.00
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 $35
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:
$400 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 $30

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $120
Emergency room visit
Emergency Care:
Copayment for Emergency Care $120
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 $120
Copayment for Worldwide Emergency Transportation $120
Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $300
Copayment for Medicare Covered Ambulance Services - Air $1250

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 $20
Prior Authorization Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:

Medicare Covered Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 40%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 40%
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 $200
Copayment for Medicare-covered Lab Services $0 to $50
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
$200 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$50 OP Diag Proc & Tests - SPC$30 OP Diag Proc & Tests - UCC$40 Sleep Study (Fac Based) - OPH$40 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 $300
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0 to $125
Home health care
Out-of-Network:

Medicare Covered Home Health Services:
Coinsurance for Medicare Covered Home Health 50%
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$421 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient care
Out-of-Network:

Medicare Covered Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 40%
Coinsurance for Medicare Covered Group Sessions 40%
Outpatient services/surgery
Out-of-Network:

Medicare Covered Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 40%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40%
$0 Diag Colonoscopy - OPH$40 Mental Health - OPH$350 Surgery Svcs - OPH$50 Wound Care - OPH_
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $40
Copayment for Medicare-covered Group Sessions $40
Prior Authorization Required for Outpatient Substance Abuse Services
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
  • Maximum plan benefit of $60 every three months for Over-The-Counter (OTC) Items
Maximum Plan Benefit of $60 every three months
Podiatry services
Out-of-Network:

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

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, crown recementation, panoramic film or diagnostic x-rays up to 1 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 adjustments to dentures, denture rebase, denture reline, denture repair, emergency diagnostic exam, tissue conditioning 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.
30% coinsurance for bridges-pontic, complete dentures, partial dentures up to 1 every 5 years.
30% coinsurance for bridges-crown up to 2 every 5 years.
$1,500 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, crown recementation, panoramic film or diagnostic x-rays up to 1 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 adjustments to dentures, denture rebase, denture reline, denture repair, emergency diagnostic exam, tissue conditioning 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.
30% coinsurance for bridges-pontic, complete dentures, partial dentures up to 1 every 5 years.
30% coinsurance for bridges-crown up to 2 every 5 years.
$1,500 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 care
Out-of-Network:

Medicare Covered Eye Exams Services:
Copayment for Medicare Covered Eye Exams $50
Coinsurance for Medicare Covered Eye Exams 50%
Coinsurance for Medicare Covered Eyewear 40%

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $50
Copayment for Routine Hearing Exams $0
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $399 to $999
  • Maximum 2 Hearing Aids every year

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, 2, and 3)

    Coverage & Cost
    Coverage
    Cost
    Annual drug deductible$350.00 (excludes Tiers 1, 2, and 3)
    Tier 1
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $10.00
    Tier 2
    • Standard retail $5.00
    • Preferred mail order $5.00
    • Standard mail order $20.00
    Tier 3
    • Standard retail $47.00
    • Preferred mail order $47.00
    • Standard mail order $47.00
    Annual drug deductible$350.00 (excludes Tiers 1, 2, and 3)
    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
    Tier 3
    • Standard retail N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    Annual drug deductible$350.00 (excludes Tiers 1, 2, and 3)
    Tier 1
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $30.00
    Tier 2
    • Standard retail $15.00
    • Preferred mail order $0.00
    • Standard mail order $60.00
    Tier 3
    • Standard retail $141.00
    • Preferred mail order $94.00
    • Standard mail order $141.00

    When reviewing California 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 California 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

    California 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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