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




Annual Out-of-Pocket Maximum


Physician Services

Primary Care or Specialist Office Visit


Annual Wellness Visit

Prostate or Breast Cancer Screening



Inpatient Care

Inpatient Hospital Care


Skilled Nursing Facility

$0 per day up to 100 days

Outpatient Care

Radiation Therapy


Outpatient Surgery


Outpatient Rehabilitation Services


Lab Services

Lab tests


X-rays and Diagnostic Radiology Services


Prescription Drug Co-Pay

Network Pharmacy

30 Day Supply

Mail Pharmacy

90 Day Supply

Tier 1 - Preferred Generic

Tier 2 - Preferred Brand (includes some generic)

Tier 3 - Non-Preferred Brand (includes some generic)

Tier 4 - Specialty Tier









Catastrophic Coverage

Select Generic


Brand Name



Greater of $3.70 copay or 5%

Greater of $9.20 copay or 5%

Part D Gap “Donut Hole” Coverage

Full Coverage

Part B Drugs - Immunosuppresses, anti-nausea, inhalation solutions, outpatient injectables, and chemotherapy drugs


Emergency Services

Emergency Care


Ambulance Services


Urgent Care


Other Medicare-Covered Benefits

Chiropractic Services

50% Coinsurance

Podiatry Services


Eye or Hearing Exam


Other Benefits Not Covered by Medicare

Routine Chiropractic Services (max 12 per year)


Hearing Aids (every 2 years)

Plan pays up to $300

Silver Sneakers Fitness Program

No cost for basic membership


24/7 Phone Access to a RN

Post-discharge Meal Delivery Program


Routine Medical Transportation (24 trips max)


The above is a summary of plan benefits and not a comprehensive list. While believed accurate, nothing listed above can change or alter the Certificate of Insurance.