Humana USAA Honor (PPO) H5216-315-000 2024 Plan Details and Costs (2024)

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

Plan ID: H5216-315-000

$0.00 Monthly Premium

Montana, Utah, Idaho, Oregon, Washington and Wyoming 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 Montana, Utah, Idaho, Oregon, Washington and Wyoming 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$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:
Coinsurance for Medicare Covered Primary Care Office Visit 50%

Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 50%

Inpatient hospital care
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 50%
Urgent care
Urgent Care:
Copayment for Urgent Care $55.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $100.00

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 $100.00
Copayment for Worldwide Emergency Transportation $100.00

Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $300.00
Copayment for Medicare Covered Ambulance Services - Air $1250.00

Health Care Services and Medical Supplies

Humana USAA Honor (PPO) covers a range of additional benefits. Learn more about Humana USAA Honor (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:
Coinsurance for Medicare Covered Chiropractic Services 50%

Diabetes supplies, training, nutrition therapy and monitoringIn-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 $0.00
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)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 19%
Prior Authorization Required for Durable Medical Equipment

Diagnostic tests, lab and radiology services, and X-rays
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 50%
Coinsurance for Medicare Covered Lab Services 50%
Coinsurance for Medicare Covered Diagnostic Radiological Services 50%
Coinsurance for Medicare Covered Therapeutic Radiological Services 50%
Coinsurance for Medicare Covered Outpatient X-Ray Services 50%

Home health care
Out-of-Network:

Home Health Services:
Coinsurance for Medicare Covered Home Health 50%

Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$480.00 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:
Coinsurance for Medicare Covered Individual Sessions 50%
Coinsurance for Medicare Covered Group Sessions 50%

Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $400.00
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $495.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $200.00
Prior Authorization Required for Ambulatory Surgical Center Services

Outpatient substance abuse care
Out-of-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual or Group Sessions 50%

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 $25.00

Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $50.00
Prior Authorization Required for Podiatry Services

Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 to 90
$0.00 per day for days 91 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 careIn Network:
Plan covers up to $1,500 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.Note: The allowance cannot be used on cosmetic services and implants.

Out of Network:
Plan covers up to $1,500 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.Note: The allowance cannot be used on 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 benefitsIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $50.00
Copayment for Routine Eye Exams $0.00

  • Maximum 1 Routine Eye Exam every year
Maximum Plan Benefit of $75.00 every year for in and out of network services combined
Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00

  • Maximum 1 Pair every year
Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair every year
Maximum Plan Benefit of $150.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Prior Authorization Required for Eyewear

Hearing Benefits

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

Coverage Details
Hearing benefitsIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $50.00
Copayment for Routine Hearing Exams $0.00

  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00

  • 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.

Coverage Details
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 & vagin*l 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

    When reviewing Montana, Utah, Idaho, Oregon, Washington and Wyoming 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 Montana, Utah, Idaho, Oregon, Washington and Wyoming that offer similar benefits at similar or lower prices than the plan above. Call 1-855-298-6309 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

    Montana Counties Served

    Beaverhead Big Horn Broadwater Carbon Cascade Chouteau Divide Fergus Flathead Gallatin Glacier Golden Valley Granite Idaho Jefferson Judith Basin Lake Liberty Madison Mckenzie Meagher Mineral Missoula Musselshell Pondera Powell Ravalli Rosebud Sanders Silver Bow Stillwater Sweet Grass Teton Toole Treasure Wheatland Yellowstone

    Utah Counties Served

    Beaver Box Elder Cache Davis duch*esne Emery Garfield Grand Iron Juab Kane Millard Morgan Piute Rich Salt Lake San Juan Summit Tooele Utah Wasatch Washington Weber

    Idaho Counties Served

    Ada Bannock Bear Lake Bingham Blaine Boise Bonneville Box Elder Camas Canyon Caribou Cassia Clark Elmore Franklin Fremont Gem Gooding Jerome Lincoln Minidoka Oneida Owyhee Payette Pend Oreille Power Twin Falls Valley Washington

    Oregon Counties Served

    Baker Clackamas Columbia Crook Deschutes Gilliam Hood River Jefferson Linn Malheur Morrow Multnomah Sherman Wallowa Washington

    Washington Counties Served

    Benton Clark Columbia Cowlitz Franklin Garfield Island Jefferson King Kitsap Kittitas Lewis Lincoln Mason Pierce Skagit Snohomish Spokane Thurston Umatilla Wahkiakum Walla Walla Whatcom

    Wyoming Counties Served

    Albany Crook Goshen Laramie Lincoln Park Teton Uinta Weston

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

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    Humana USAA Honor (PPO) H5216-315-000 2024 Plan Details and Costs (2024)
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