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.

UnitedHealthcare® Group Medicare Advantage (PPO)

2024 materials

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	UnitedHealthcare® Group Medicare Advantage (PPO)
UnitedHealthcare® Group Medicare Advantage (PPO)
Annual medical deductible	$0
Annual medical deductible
$0
Annual out-of-pocket maximum	$2, 500
Annual out-of-pocket maximum
$2, 500
Office and clinic visits	$15 copay for primary care $20 copay for specialist visit
Office and clinic visits
$15 copay for primary care $20 copay for specialist visit
Hospital services (inpatient)	$100 copay per day for days 1-3 $0 copay for days 4 and beyond
Hospital services (inpatient)
$100 copay per day for days 1-3 $0 copay for days 4 and beyond
Hospital services (outpatient)	$125 copay
Hospital services (outpatient)
$125 copay
Hearing aids	$2, 400 hearing aid allowance per calendar year *
Hearing aids
$2, 400 hearing aid allowance per calendar year *
Calendar year pharmacy out-of-pocket maximum	$5, 000 per individual
Calendar year pharmacy out-of-pocket maximum
$5, 000 per individual
Prescription drug coverage	Retail up to a (31-day) supply Tier 1 – Preferred Generic: up to an $8 copay Tier 2 – Generic: up to a $15 copay Tier 3 – Preferred Brand: 40% coinsurance to $250 max per script Tier 4 – Non-Preferred Drug: 40% coinsurance to $250 max per script Tier 5 – Specialty: 40% coinsurance to $250 max per script
Prescription drug coverage
Retail up to a (31-day) supply Tier 1 – Preferred Generic: up to an $8 copay Tier 2 – Generic: up to a $15 copay Tier 3 – Preferred Brand: 40% coinsurance to $250 max per script Tier 4 – Non-Preferred Drug: 40% coinsurance to $250 max per script Tier 5 – Specialty: 40% coinsurance to $250 max per script

*Hearing aids ordered through providers other than UnitedHealthcare Hearing are not covered.

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.