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.

 

ConocoPhillips Core (PPO)

2024 materials

Plan

ConocoPhillips Plus (PPO)

2024 materials

Plan

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 and costs

ConocoPhillips Core (PPO)

ConocoPhillips Plus (PPO) 

ConocoPhillips Core (PPO)

ConocoPhillips Plus (PPO) 
Annual medical deductible

$0

$0
Annual medical deductible

$0

$0
Annual out-of-pocket maximum

$2800

$500
Annual out-of-pocket maximum

$2800

$500
Office and clinic visits

$15 copay for primary care office (includes non-MD office visits)

$30 copay for specialist office visit

$15 copay for Virtual Visit

$15 copay for telemedicine

$5 copay for primary care office (includes non-MD office visits)

$10 copay for specialist office visit

$5 copay for Virtual Visit

 

$5 copay for telemedicine
Office and clinic visits

$15 copay for primary care office (includes non-MD office visits)

$30 copay for specialist office visit

$15 copay for Virtual Visit

$15 copay for telemedicine

$5 copay for primary care office (includes non-MD office visits)

$10 copay for specialist office visit

$5 copay for Virtual Visit

 

$5 copay for telemedicine
Hospital services (inpatient)

$250 copay for day 1

$50 copay for day 1
Hospital services (inpatient)

$250 copay for day 1

$50 copay for day 1
Hospital services (outpatient)

$100 copay for outpatient surgery

$100 copay for outpatient hospital services

$30 copay for outpatient mental health/substance abuse (individual visit)

$15 copay for outpatient mental health/substance abuse (group visit)

$55 copay for partial hospitalization (mental health day treatment) per day

$25 copay for outpatient surgery

$25 copay for outpatient hospital services

 

$20 copay for outpatient mental health/substance abuse (individual visit)

$10 copay for outpatient mental health/substance abuse (group visit)

 

$5 copay for partial hospitalization (mental health day treatment) per day

 

$10 copay Comprehensive Outpatient Rehabilitation Facility (CORF)

$10 copay occupational therapy

$10 copay physical therapy and speech/language therapy

 

$10 copay cardiac rehabilitation

 

$10 copay intensive cardiac rehabilitation

 

$10 copay pulmonary rehabilitation

 

$10 copay supervised exercise therapy (SET) for Symptomatic peripheral artery disease (PAD)

$0 copay kidney dialysis
Hospital services (outpatient)

$100 copay for outpatient surgery

$100 copay for outpatient hospital services

$30 copay for outpatient mental health/substance abuse (individual visit)

$15 copay for outpatient mental health/substance abuse (group visit)

$55 copay for partial hospitalization (mental health day treatment) per day

$25 copay for outpatient surgery

$25 copay for outpatient hospital services

 

$20 copay for outpatient mental health/substance abuse (individual visit)

$10 copay for outpatient mental health/substance abuse (group visit)

 

$5 copay for partial hospitalization (mental health day treatment) per day

 

$10 copay Comprehensive Outpatient Rehabilitation Facility (CORF)

$10 copay occupational therapy

$10 copay physical therapy and speech/language therapy

 

$10 copay cardiac rehabilitation

 

$10 copay intensive cardiac rehabilitation

 

$10 copay pulmonary rehabilitation

 

$10 copay supervised exercise therapy (SET) for Symptomatic peripheral artery disease (PAD)

$0 copay kidney dialysis
Prescription drug coverage

Retail

 

Tier 1: $5 copay

Tier 2: $45 copay

Tier 3: 40% coinsurance

Tier 4: 33% coinsurance

Estimate Drug Cost

Retail

 

Tier 1: $5 copay

Tier 2: $45 copay

Tier 3: 40% coinsurance

Tier 4: 33% coinsurance

Estimate Drug Cost
Prescription drug coverage

Retail

 

Tier 1: $5 copay

Tier 2: $45 copay

Tier 3: 40% coinsurance

Tier 4: 33% coinsurance

Estimate Drug Cost

Retail

 

Tier 1: $5 copay

Tier 2: $45 copay

Tier 3: 40% coinsurance

Tier 4: 33% coinsurance

Estimate Drug Cost

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.