Humana USAA Honor with Rx (PPO) H5216-307-000 2024 Plan Details and Costs (2024)

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00

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

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $100.00

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $100.00
Copayment for Worldwide Emergency Transportation $100.00

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

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15.00
Copayment for Routine Care $0.00
Prior Authorization Required for Chiropractic Services

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:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment

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 Services:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services

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

Outpatient Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 50%
Coinsurance for Medicare Covered Group Sessions 50%

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 Services:
Copayment for Medicare Covered Individual or Group Sessions $85.00
Coinsurance for Medicare Covered Individual or Group Sessions 50%

Over-The-Counter (OTC) Items:
Coinsurance for Non-Medicare Covered Over-The-Counter (OTC) Items 50%
Maximum Plan Benefit of $50.00

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 50%
Podiatry Services:
Copayment for Non-Medicare Covered Podiatry Services $10.00

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

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.

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 50%
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 Exams:
Copayment for Medicare Covered Benefits $45.00
Copayment for Routine Hearing Exams $0.00

• Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $399.00 to $999.00

• Maximum 2 Hearing Aids every year

Medicare-covered Zero Dollar Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0.00
Coinsurance for Medicare Covered Medicare-covered Preventive Services 50%

• Standard retail $0.00
• Preferred mail order $0.00
• Standard mail order $10.00

• Standard retail $5.00
• Preferred mail order $5.00
• Standard mail order $20.00

• Standard retail N/A
• Preferred mail order N/A
• Standard mail order N/A

• Standard retail N/A
• Preferred mail order N/A
• Standard mail order N/A

• Standard retail $0.00
• Preferred mail order $0.00
• Standard mail order $30.00

• Standard retail $15.00
• Preferred mail order $0.00
• Standard mail order $60.00

• Summary of benefits
• Evidence of coverage
• Star ratings