United Healthcare
Medicare Advantage HMO including Rx Coverage
This UnitedHealthcare Group Medicare Advantage (HMO) plan has a network of providers that may meet your needs. Like other Medicare Advantage (HMO) plans, you must reside in the plan service area. You can confirm plan availability in your area by calling UnitedHealthcare at (877) 714-0178, TTY 711, 8 a.m. – 8 p.m. local time, 7 days a week, or by visiting www.UHCretiree.com
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Annual |
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| Deductible |
$0 |
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| Annual Out-of-Pocket Maximum |
$2,000 |
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Physician Services |
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| Primary Care or Specialist Office Visit |
$20 |
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| Annual Wellness VisitProstate or Breast Cancer ScreeningImmunizations |
$0 |
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Inpatient Care |
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| Inpatient Hospital Care |
$0 |
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| Skilled Nursing Facility |
$0 per day up to 100 days |
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Outpatient Care |
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| Radiation Therapy |
$0 |
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| Outpatient Surgery |
$0 |
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| Outpatient Rehabilitation Services |
$20 |
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Lab Services |
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| Lab tests |
$0 |
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| X-rays and Diagnostic Radiology Services |
$0 |
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Prescription Drug Co-Pay |
Network Pharmacy 30 Day Supply |
Mail Pharmacy 90 Day Supply |
| Tier 1 – Preferred GenericTier 2 – Preferred Brand (includes some generic)Tier 3 – Non-Preferred Brand (includes some generic)Tier 4 – Specialty Tier |
$10 $20 $20 $20 |
$20 $40 $40 $40 |
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Catastrophic Coverage Select Generic Generic Brand Name |
$0 Greater of $3.70 copay or 5% Greater of $9.20 copay or 5% |
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| Part B Drugs – Immunosuppresses, anti-nausea, inhalation solutions, outpatient injectables, and chemotherapy drugs |
$0 |
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Emergency Services |
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| Emergency Care |
$50 |
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| Ambulance Services |
$50 |
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| Urgent Care |
$20 |
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Other Medicare-Covered Benefits |
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| Chiropractic Services |
50% Coinsurance |
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| Podiatry Services |
$20 |
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| Eye or Hearing Exam |
$20 |
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Other Benefits Not Covered by Medicare |
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| Routine Chiropractic Services (max 12 per year) |
$20 |
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| Hearing Aids (every 2 years) |
Plan pays up to $300 |
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| Renew Active Fitness Program |
No cost for basic membership |
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| NurseLineSM |
24/7 Phone Access to a RN |
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| Post-discharge Meal Delivery Program |
Included |
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| Routine Medical Transportation (24 trips max) |
$0 |
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