Humana USAA Honor with Rx (PPO) H5216-305-000 2024 Plan Details and Costs

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.

Basic Costs and Coverage

Coverage	Details
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	$8,000.00
Primary care doctor visit	Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $0.00
Specialty doctor visit	Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $45.00
Inpatient hospital care	Out-of-Network: $425.00 per day for days 1 to 5 $0.00 per day for days 6 to 90
Urgent care	Urgent Care: Copayment for Urgent Care $55.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $90.00
Emergency room visit	Emergency Care: Copayment for Emergency Care $100.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $90.00 Copayment for Worldwide Emergency Transportation $90.00
Ambulance transportation	In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $300.00 Air Ambulance: Copayment for Air Ambulance Services $300.00 Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

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

Coverage	Details
Chiropractic services	Out-of-Network: Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $15.00 Chiropractic Services: Copayment for Non-Medicare Covered Chiropractic Services $0.00
Diabetes supplies, training, nutrition therapy and monitoring	In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0.00 Coinsurance for Medicare-covered Diabetic Supplies 10% to 20% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10.00 Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Durable medical equipment (DME)	Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 20%
Diagnostic tests, lab and radiology services, and X-rays	In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $105.00 Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20% Copayment for Medicare-covered Lab Services $0.00 to $55.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $635.00 Copayment for Medicare-covered Therapeutic Radiological Services $45.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0.00 to $125.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Home health care	In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services
Mental health inpatient care	In-Network: Psychiatric Hospital Services: $425.00 per day for days 1 to 4 $0.00 per day for days 5 to 90 Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient care	Out-of-Network: Outpatient Mental Health Services: Copayment for Medicare Covered Individual Sessions $30.00 Copayment for Medicare Covered Group Sessions $30.00
Outpatient services/surgery	In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $425.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $400.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 to $375.00 Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse care	Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual or Group Sessions $30.00 to $100.00
Over-the-counter items	Out-of-Network: Over-The-Counter (OTC) Items: Coinsurance for Non-Medicare Covered Over-The-Counter (OTC) Items 50% Maximum Plan Benefit of $50.00
Podiatry services	In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $45.00 Copayment for Routine Foot Care $10.00 Maximum 6 visits every year Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) care	Out-of-Network: $0.00 per day for days 1 to 20 $203.00 per day for days 21 to 100

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	In Network: 0% coinsurance for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. 0% coinsurance for panoramic film or diagnostic x-rays up to 1 every 5 years. 0% coinsurance for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. 0% coinsurance for emergency diagnostic exam up to 1 per year. 0% coinsurance for fluoride treatment, periodic oral exam, prophylaxis (cleaning) up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. 0% coinsurance for necessary anesthesia with covered service up to unlimited per year. $25 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $25 copayment for scaling for moderate inflammation up to 1 every 3 years. $25 copayment for crown recementation, bridge recementation up to 1 every 5 years. $25 copayment for emergency treatment for pain up to 2 per year. $25 copayment per tooth for amalgam and/or composite filling, simple or surgical extraction up to unlimited per year. 50% coinsurance for occlusal adjustment up to 1 every 3 years. 50% coinsurance for bridges-pontic up to 1 every 5 years. 50% coinsurance for bridges-crown up to 2 every 5 years. 50% coinsurance for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime. 50% coinsurance for oral surgery up to 2 per year. $3,000 combined maximum benefit coverage amount per year for preventive and comprehensive benefits. Out of Network: 0% coinsurance for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. 0% coinsurance for panoramic film or diagnostic x-rays up to 1 every 5 years. 0% coinsurance for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. 0% coinsurance for emergency diagnostic exam up to 1 per year. 0% coinsurance for fluoride treatment, periodic oral exam, prophylaxis (cleaning) up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. 0% coinsurance for necessary anesthesia with covered service up to unlimited per year. $25 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $25 copayment for scaling for moderate inflammation up to 1 every 3 years. $25 copayment for crown recementation, bridge recementation up to 1 every 5 years. $25 copayment for emergency treatment for pain up to 2 per year. $25 copayment per tooth for amalgam and/or composite filling, simple or surgical extraction up to unlimited per year. 50% coinsurance for occlusal adjustment up to 1 every 3 years. 50% coinsurance for bridges-pontic up to 1 every 5 years. 50% coinsurance for bridges-crown up to 2 every 5 years. 50% coinsurance for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime. 50% coinsurance for oral surgery up to 2 per year. $3,000 combined maximum benefit coverage amount per year for preventive and comprehensive benefits. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Coverage

Details

Dental care

In Network:
0% coinsurance for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. 0% coinsurance for panoramic film or diagnostic x-rays up to 1 every 5 years. 0% coinsurance for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. 0% coinsurance for emergency diagnostic exam up to 1 per year. 0% coinsurance for fluoride treatment, periodic oral exam, prophylaxis (cleaning) up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. 0% coinsurance for necessary anesthesia with covered service up to unlimited per year. $25 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $25 copayment for scaling for moderate inflammation up to 1 every 3 years. $25 copayment for crown recementation, bridge recementation up to 1 every 5 years. $25 copayment for emergency treatment for pain up to 2 per year. $25 copayment per tooth for amalgam and/or composite filling, simple or surgical extraction up to unlimited per year. 50% coinsurance for occlusal adjustment up to 1 every 3 years. 50% coinsurance for bridges-pontic up to 1 every 5 years. 50% coinsurance for bridges-crown up to 2 every 5 years. 50% coinsurance for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime. 50% coinsurance for oral surgery up to 2 per year. $3,000 combined maximum benefit coverage amount per year for preventive and comprehensive benefits.

Out of Network:
0% coinsurance for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. 0% coinsurance for panoramic film or diagnostic x-rays up to 1 every 5 years. 0% coinsurance for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. 0% coinsurance for emergency diagnostic exam up to 1 per year. 0% coinsurance for fluoride treatment, periodic oral exam, prophylaxis (cleaning) up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. 0% coinsurance for necessary anesthesia with covered service up to unlimited per year. $25 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $25 copayment for scaling for moderate inflammation up to 1 every 3 years. $25 copayment for crown recementation, bridge recementation up to 1 every 5 years. $25 copayment for emergency treatment for pain up to 2 per year. $25 copayment per tooth for amalgam and/or composite filling, simple or surgical extraction up to unlimited per year. 50% coinsurance for occlusal adjustment up to 1 every 3 years. 50% coinsurance for bridges-pontic up to 1 every 5 years. 50% coinsurance for bridges-crown up to 2 every 5 years. 50% coinsurance for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime. 50% coinsurance for oral surgery up to 2 per year. $3,000 combined maximum benefit coverage amount per year for 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.

Coverage	Details
Vision benefits	Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $0.00 to $45.00 Copayment for Medicare Covered Eyewear $0.00 Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $0.00 Copayment for Non-Medicare Covered Eyewear $0.00

Hearing Benefits

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

Coverage	Details
Hearing benefits	Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $45.00 Non-Medicare Covered Hearing Services: Coinsurance for Non-Medicare Covered Hearing Exams 50% Coinsurance for Non-Medicare Covered Hearing Aids 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 Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00

Prescription Drug Costs and Coverage

The Humana USAA Honor 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 $5.00 Preferred mail order $5.00 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 $15.00 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	Summary of benefits Evidence of coverage Star ratings

Links to plan documents

Michigan Counties Served

Alcona Alger Allegan Alpena Antrim Arenac Baraga Barry Bay Benzie Berrien Branch Calhoun Cass Charlevoix Cheboygan Chippewa Clare Clinton Crawford Delta Dickinson Eaton Emmet Genesee Gladwin Gogebic Grand Traverse Gratiot Hillsdale Houghton Huron Ingham Ionia Iosco Iron Isabella Jackson Kalamazoo Kalkaska Kent Keweenaw Lake Lapeer Leelanau Lenawee Livingston Luce Mackinac Macomb Manistee Marquette Mason Mecosta Menominee Midland Missaukee Monroe Montcalm Montmorency Muskegon Newaygo Oakland Oceana Ogemaw Ontonagon Osceola Oscoda Otsego Ottawa Presque Isle Roscommon Saginaw Saint Clair Saint Joseph Sanilac Schoolcraft Shiawassee Tuscola Van Buren Washtenaw Wayne Wexford

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