LGHIB Retirees – 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

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Benefits and costs UnitedHealthcare® Group Medicare Advantage 
Annual medical deductible $0
Annual  out-of-pocket maximum $6,700
Office and clinic visits $20 copay for primary care
$30 copay for specialist visit
$0 copay for Virtual Doctor Visit
Behavioral health $20 copay in office
$20 copay for Virtual Behavioral Health Visit
Urgent care $30 copay
Emergency $80 copay
Hospital services (inpatient) $200 copay day 1
$50 copay days 2-5
$0 copay days 6-Unlimited
Hospital services (outpatient) $0 copay 
Diabetic supplies and monitors

In-network: $0 copay
Out-of-network: $0 copay

For diabetes monitoring supplies, the plan covers the following brands of blood glucose monitors and test strips: OneTouch® Ultra® 2, OneTouch® Verio™, OneTouch® UltraMini™, ACCU-CHEK® Aviva, ACCU-CHEK® Compact, ACCU-CHEK® SmartView. Other brands are not covered by our plan.

If you use a brand of supplies that is not covered by our plan, you should speak with your doctor to get a new prescription for a covered brand.

Prescription drug coverage

Tier 1 Generic – up to 30-day supply: $10 copay

Tier 2* Preferred Brand – up to 30-day supply: 20% coinsurance

Tier 3* Non-Preferred Brand – up to 30-day supply: 20% coinsurance

Tier 4* Specialty Tier – up to 30-day supply: 20% coinsurance

*For Tiers 2, 3 & 4 there is a $100 deductible before your coinsurance begins

Questions? We're here to help.
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LGHIB


Group retiree benefits for LGHIB

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IMPORTANT DATES

2022 Open Enrollment Period

Begins: 11/1/2021
Ends: 11/30/2021

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Last updated: 04.20.2021 at 12:01 AM CT  H2001_042021GMR