ASRS and PSPRS Group Retiree – Review Plan Benefits
UnitedHealthcare®
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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)

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

$25 copay for each Medicare-covered urgently needed care visit
Prescription drug coverage $10 copay generic Tier 1
$20 copay generic Tier 1 mail-order

$40 copay brand Tier 2, 3, 4
$80 copay brand Tier 2, 3, 4 mail-order
$10 copay generic Tier 1
$20 copay generic Tier 1 mail-order

$35 copay brand Tier 2, 3, 4
$70 copay brand Tier 2, 3, 4 mail-order
Coverage gap; standard Medicare amount TrOOP, TDE, Catastrophic

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Arizona State Retirement System (ASRS)

Group retiree benefits for
ASRS and PSPRS retirees

This is not my group.
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IMPORTANT DATES

2021 Open Enrollment Period

Begins: 11/1/2020
Ends: 11/30/2020

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Last updated: 11.03.2020 at 12:01 AM  H2001_110320DMR