ASRS and PSPRS Group Retiree – Review Plan Benefits
UnitedHealthcare®
text size

Review plan benefits & costs

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

UnitedHealthcare® Group Medicare Advantage
(HMO)

file

UnitedHealthcare® Group Medicare Advantage (PPO)

Benefits and costs UnitedHealthcare® Group Medicare Advantage (HMO) UnitedHealthcare® Group Medicare Advantage (PPO)
Annual medical deductible None $150 deductible on first inpatient hospitalization annually
Annual medical out-of-pocket maximum $4,000 $5,000
Office and clinic visits $15 copay for primary care
$30 copay for specialist visit
$15 copay for primary care
$25 copay for specialist visit
Hospital services (inpatient) $100 copay per admission $0 after $150 annual inpatient deductible has been met
Hospital emergency services (outpatient) $50 copay for each Medicare-covered emergency room visit (waived if admitted)

$15 copay for each Medicare-covered urgent care visit
$50 copay for each Medicare-covered emergency room visit (waived if admitted)

$25 copay for each Medicare-covered urgent care visit
Prescription drug coverage

Retail (30-day supply)
Tier 1: $10 copay
Tier 2: $40 copay
Tier 3: $40 copay
Tier 4: $40 copay


Mail order (90-day supply)
Tier 1: $20 copay
Tier 2: $80 copay
Tier 3: $80 copay
Tier 4: $80 copay


The UnitedHealthcare Group Medicare Advantage HMO plan offers additional coverage during the Coverage Gap stage of the Prescription Drug Plan. After your total drug costs reach $4,130, the plan continues to pay its share of the cost of your drugs and you pay your share of the cost (your copay) until you reach the Catastrophic Coverage stage. Please see Plan guide for details.

Retail (30-day supply)
Tier 1: $10 copay
Tier 2: $35 copay
Tier 3: $35 copay
Tier 4: $35 copay


Mail order (90-day supply)
Tier 1: $20 copay
Tier 2: $70 copay
Tier 3: $70 copay
Tier 4: $70 copay


The UnitedHealthcare Group Medicare Advantage PPO plan offers standard coverage during the Coverage Gap stage of the Prescription Drug Plan. After your total drug costs reach $4,130, you pay 25% of the price for brand name and generic drugs until you reach the Catastrophic Coverage stage. Please see Plan Guide for details.

Already a member?

file

New user? Register now

Questions? We're here to help.
Contact us   

file
Arizona State Retirement System (ASRS)

Group retiree benefits for
ASRS and PSPRS retirees

This is not my group.
Back to uhcretiree.com »

IMPORTANT DATES

2022 Open Enrollment Period

Begins: 11/1/2021
Ends: 11/30/2021

file

Virtual Education Center 


It’s all the information you need to help you understand and access your MAPD plan benefits — in one place, at any time, from your favorite device. Let’s get started »

PDF (Portable Document Format) files can be viewed with Adobe® Reader®. If you don’t already have this viewer on your computer, download it free from the Adobe Web site - opens in a new window.

Last updated: 10.01.2021 at 12:01 AM  H2001_083121DMR