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Humana USAA Honor Giveback (PPO) - H5216-235-000

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: H5216-235-000

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

$0.00

Monthly Premium

Tennessee 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 Tennessee 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-$1.00
Out-of-pocket maximum$3,400.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visit
Out-of-Network:

Doctor Office Visit Services:
Coinsurance for Medicare Covered Primary Care Office Visit 30%
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit Services:
Coinsurance for Medicare Covered Physician Specialist Office Visit 30%
Inpatient hospital careIn-Network:

Acute Hospital Services:
$280 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 $65

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $140
Emergency room visit
Emergency Care:
Copayment for Emergency Care $140
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 $140
Copayment for Worldwide Emergency Transportation $140
Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $315
Coinsurance for Medicare Covered Ambulance Services - Air 20%

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).

CoverageDetails
Chiropractic services
Out-of-Network:

Medicare Covered Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 30%
Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:

Medicare Covered Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 30%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 30%
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 15%
Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-rays
Out-of-Network:

Medicare Covered Diagnostic Procedures/Tests Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
30%
Coinsurance for Medicare Covered Lab Services
30%
Coinsurance for Medicare Covered Diagnostic Radiological Services 30%
Coinsurance for Medicare Covered Therapeutic Radiological Services 30%
Coinsurance for Medicare Covered Outpatient X-Ray Services 30%
$10 Coumadin Clinic Svcs - OPH$45 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$25 OP Diag Proc & Tests - SPC$65 OP Diag Proc & Tests - UCC$25 Sleep Study (Fac Based) - OPH$25 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_
Home health care
Out-of-Network:

Medicare Covered Home Health Services:
Coinsurance for Medicare Covered Home Health 30%
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$280 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 30%
Coinsurance for Medicare Covered Group Sessions 30%
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $250
Prior Authorization Required for Outpatient Hospital Services
$0 Diag Colonoscopy - OPH$25 Mental Health - OPH$250 Surgery Svcs - OPH$25 Wound Care - OPH_

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $280
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $200
Prior Authorization Required for Ambulatory Surgical Center Services
$0 Diag Colonoscopy - ASC$200 Surgery Svcs - ASC_
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $25
Copayment for Medicare-covered Group Sessions $25
Prior Authorization Required for Outpatient Substance Abuse Services
Podiatry services
Out-of-Network:

Medicare Covered Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 30%
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$20 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, crown recementation, panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for 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.
30% coinsurance for bridges-pontic up to 1 every 5 years.
30% coinsurance for other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime.
30%-40% coinsurance for crown up to 1 every 5 years.
30%-40% coinsurance for bridges-crown up to 2 every 5 years.
$2,000 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, crown recementation, panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for 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.
30% coinsurance for bridges-pontic up to 1 every 5 years.
30% coinsurance for other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime.
30%-40% coinsurance for crown up to 1 every 5 years.
30%-40% coinsurance for bridges-crown up to 2 every 5 years.
$2,000 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 $25
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 $150 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:
Coinsurance for Medicare Covered Hearing Exams 30%

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 programs
Out-of-Network:

Medicare Covered Medicare-covered Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0

When reviewing Tennessee 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 Tennessee that offer similar benefits at similar or lower prices than the plan above. Call 1-888-876-5731 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Tennessee 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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