SDCERA 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® Senior Supplement +
UnitedHealthcare® MedicareRx for Groups (PDP)

Benefits and costs UnitedHealthcare® Group
Medicare Advantage (HMO)
UnitedHealthcare® Senior Supplement +
UnitedHealthcare® MedicareRx for Groups  
Annual medical deductible None None
Annual out-of-pocket maximum $6,700 None
Office and clinic visits $20 copay primary care
$20 copay specialist visit
$0 copay
Hospital services (inpatient) $0 copay Days 1-60: Plan pays 100% of Medicare Part A deductible

Days 61-90: Plan pays 100% copayment per day

Days 91-150 (while using 60 lifetime reserve days): Plan pays 100% copayment per day

Additional Days (after 60 lifetime reserve days are used): Plan pays 100% coinsurance

Beyond 365 lifetime additional days: Plan does not cover and member pays the balance
Hospital services (outpatient) $0 copay surgery and observation

$0 copay all other procedures
Medicare Part B Deductible: Plan pays 100%

Medicare Part B Excess Charges: Plan pays 100%
Prescription drug coverage

Tier 1:
$10 copay retail
$20 copay mail order

Tier 2:
$30 copay retail
$60 copay mail order

Tier 3:
$30 copay retail
$60 copay mail order

Specialty:
$30 copay retail
$60 copay mail order

Initial coverage limit: $4,130


Catastrophic coverage:

After your total out-of-pocket costs reach $6,550, you enter the Catastrophic Coverage stage.  In this stage, you pay a small copay, of $3.70 for generic drugs and $9.20 for brand name and specialty drugs and you stay in this stage for the rest of the plan year.

Tier 1:
$10 copay retail
$20 copay mail order

Tier 2:
$35 copay retail
$70 copay mail order

Tier 3:
$50 copay retail
$100 copay mail order

Specialty:
$50 copay retail
$100 copay mail order


Initial coverage limit: $4,130


Catastrophic coverage:

After your total out-of-pocket costs reach $6,550, you enter the Catastrophic Coverage stage.  In this stage, you pay a small copay, of $3.70 for generic drugs and $9.20 for brand name and specialty drugs and you stay in this stage for the rest of the plan year.

Prescription drug coverage is provided through a separate plan – UnitedHealthcare MedicareRx for Groups (PDP)

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Group retiree benefits for SDCERA

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IMPORTANT DATES

2021 Open Enrollment Period

Began: 11/01/2020
Ended: 11/20/2020

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Last updated: 04.20.2021 at 12:01 AM CT  H0543_020921IMR