Humana USAA Honor Giveback (PPO)

In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45
Prior Authorization Required for Doctor Specialty Visit

Out-of-Network:

Acute Hospital Services:
Coinsurance for Acute Hospital Services per Stay 50%

Urgent Care:
Copayment for Urgent Care $50

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $50

Emergency Care:
Copayment for Emergency Care $130
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 $130
Copayment for Worldwide Emergency Transportation $325

Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $325
Copayment for Medicare Covered Ambulance Services - Air $1800

Out-of-Network:

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 50%
In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Prior Authorization Required for Chiropractic Services

Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 10% to 50%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 50%

Out-of-Network:

Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 50%

Out-of-Network:

Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $50
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 50%
Coinsurance for Medicare Covered Lab Services 50%
Copayment for Medicare Covered Diagnostic Radiological Services $0
Coinsurance for Medicare Covered Diagnostic Radiological Services 50%
Coinsurance for Medicare Covered Therapeutic Radiological Services 50%
Copayment for Medicare Covered Outpatient X-Ray Services $50
Coinsurance for Medicare Covered Outpatient X-Ray Services 50%
$100 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$45 OP Diag Proc & Tests - SPC$50 OP Diag Proc & Tests - UCC$175 Sleep Study (Fac Based) - OPH$100 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home

In-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services

In-Network:

Psychiatric Hospital Services:
$360 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services

Out-of-Network:

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

Out-of-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0
Coinsurance for Medicare Covered Outpatient Hospital Services 50%
Copayment for Medicare Covered Ambulatory Surgical Center Services $0
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50%
$0 Diag Colonoscopy - OPH$0 Mental Health - OPH$550 Surgery Svcs - OPH$45 Wound Care - OPH

Out-of-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 50%
Coinsurance for Medicare Covered Group Sessions 50%
In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Prior Authorization Required for Outpatient Substance Abuse Services

In-Network:
$75 quarterly allowance on a prepaid spending card to buy approved over-the-counter health and wellness products at participating retail locations or through the plan's approved OTC mail order vendor.
Unused amount expires at the end of the quarter or upon disenrollment from the plan, whichever occurs first.

Out-of-Network:
95% coinsurance.
Member is required to pay the full cost at the time of service when utilizing an out-of-network provider. To receive reimbursement from Humana for eligible items/services, the member must submit required documentation. Reimbursement will be limited to up to 5% of the allowed amount on eligible items/services.
Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 50%
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $45
Prior Authorization Required for Podiatry Services

Out-of-Network:

Skilled Nursing Facility Services:
Coinsurance for Skilled Nursing Facility per Stay 50%

In-Network:
$0 copayment for amalgam and/or composite filling up to 1 per tooth per surface every 2 years.
$0 copayment for crown recementation up to 1 every 2 years.
$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 up to 1 every 3 years.
$0 copayment for crown, denture repair - additions, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years.
$0 copayment for bridges-pontic, complete dentures, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years.
$0 copayment for bridges-crown up to 2 every 5 years.
$0 copayment per tooth for root canal, root canal retreatment, simple or surgical extraction up to 1 per lifetime.
$0 copayment for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
$0 copayment for bitewing x-rays, bridge recementation, denture rebase, denture reline, scaling for moderate inflammation, tissue conditioning up to 1 per year.
$0 copayment for denture repair - broken teeth up to 2 per tooth per year.
$0 copayment for adjustments to dentures, denture repair - base and framework, emergency diagnostic exam, emergency treatment for pain, necessary general anesthesia with covered service, 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 intraoral x-rays up to 6 per year.
$0 copayment for necessary incremental anesthesia with covered service up to as needed with covered codes per year.
$5,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.

Out-of-Network:
$0 copayment for amalgam and/or composite filling up to 1 per tooth per surface every 2 years.
$0 copayment for crown recementation up to 1 every 2 years.
$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 up to 1 every 3 years.
$0 copayment for crown, denture repair - additions, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years.
$0 copayment for bridges-pontic, complete dentures, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years.
$0 copayment for bridges-crown up to 2 every 5 years.
$0 copayment per tooth for root canal, root canal retreatment, simple or surgical extraction up to 1 per lifetime.
$0 copayment for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
$0 copayment for bitewing x-rays, bridge recementation, denture rebase, denture reline, scaling for moderate inflammation, tissue conditioning up to 1 per year.
$0 copayment for denture repair - broken teeth up to 2 per tooth per year.
$0 copayment for adjustments to dentures, denture repair - base and framework, emergency diagnostic exam, emergency treatment for pain, necessary general anesthesia with covered service, 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 intraoral x-rays up to 6 per year.
$0 copayment for necessary incremental anesthesia with covered service up to as needed with covered codes per year.
$5,000 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.

In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $45
Copayment for Routine Eye Exams $0

• Maximum 1 Routine Eye Exams every year

Prior Authorization Required for Eye Exams
$0 Diab Eye Exam - All POTs$45 Vision Svcs (MC) - SPC

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 $250 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 $100 less than the PLUS network.

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $45
Copayment for Routine Hearing Exams $0

• Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0

• Maximum 4 visits every year

Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $499 to $725

• Maximum 2 Hearing Aids every year

Out-of-Network:

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