Coverage and benefits

Get a quick overview of your plan benefits and costs and find more detailed information about additional benefits and programs.

Important Information about your Part D Vaccine and Insulin Coverage

What You Pay for Vaccines – Our plan covers most adult Part D vaccines at no cost to you.

What You Pay for Insulin – You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan. Refer to your plan materials.

LSU First Medicare Retiree (PPO) plan administered by UnitedHealthcare ®

2024 Materials

Preventive services

The following preventive services are covered under your plan for a $0 copay when you visit your primary care provider:

Annual Wellness Exam
Annual Routine Physical
Screenings for certain Cancers (Prostate, colorectal, breast cancer)
Screening for diabetes
Smoking and Tobacco Use Cessation

For more information about these preventive services, please call the Customer Service number on your member ID card.

Benefits and costs

Plan options and costs
Benefits	LSU First Medicare Retiree (PPO) plan administered by UnitedHealthcare®
LSU First Medicare Retiree (PPO) plan administered by UnitedHealthcare®
Annual medical deductible	None
Annual medical deductible
None
Office and clinic visits	$0 copay
Office and clinic visits
$0 copay
Hospital services (inpatient)	$0 copay
Hospital services (inpatient)
$0 copay
Hospital services (outpatient)	$0 copay
Hospital services (outpatient)
$0 copay
Emergency room services	$50 copay
Emergency room services
$50 copay
Prescription drug coverage	Retail: Tier 1 – Generic: $0 copay Tier 2 – Preferred Brand: $40 copay Tier 3 – Non-Preferred Brand: $70 copay Tier 4 – Specialty: $100 copay Mail Order: Tier 1 – Generic: $0 copay Tier 2 – Preferred Brand: $120 copay Tier 3 – Non-Preferred Brand: $210 copay Tier 4 – Specialty: $300 copay After your total out-of-pocket costs reach $7,050, you enter the Catastrophic Coverage stage. In this stage, you pay a small copay, of $3.95 for generic drugs and $9.85 for brand name and specialty drugs and you stay in this stage for the rest of the plan year.
Prescription drug coverage
Retail: Tier 1 – Generic: $0 copay Tier 2 – Preferred Brand: $40 copay Tier 3 – Non-Preferred Brand: $70 copay Tier 4 – Specialty: $100 copay Mail Order: Tier 1 – Generic: $0 copay Tier 2 – Preferred Brand: $120 copay Tier 3 – Non-Preferred Brand: $210 copay Tier 4 – Specialty: $300 copay After your total out-of-pocket costs reach $7,050, you enter the Catastrophic Coverage stage. In this stage, you pay a small copay, of $3.95 for generic drugs and $9.85 for brand name and specialty drugs and you stay in this stage for the rest of the plan year.

Disclaimer

Out-of-network/non-contracted providers are under no obligation to treat UnitedHealthcare members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the costsharing that applies to out-of-network services.