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
View 2021 plan details:
- Plan Guide (PDF)(1.1 MB)
- Benefit Highlights (PDF)(41.2 KB)
- Summary of Benefits (PDF)(98.6 KB)
- Evidence of Coverage (PDF)(1013.8 KB)
- FAQs »
Preventive services
The following preventive services are covered under your plan for a $0 copay when you visit your primary care provider:
- Screening and counseling to reduce alcohol misuse
- Screening for depression in adults
- Intensive behavioral therapy to reduce cardiovascular disease risk
- Screening and counseling for obesity
- Screening for Sexually Transmitted Infections (STIs) and high intensity behavioral counseling to prevent STIs
For information about these preventive services, please call the Customer Service number on the back of your plan ID card.
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.
| Benefits and costs | UnitedHealthcare® Group Medicare Advantage |
|---|---|
| Annual medical deductible | $0 |
| Annual out-of-pocket maximum | $6,700 |
| Office and clinic visits | $10 copay for primary care $15 copay for specialist visit $0 copay for Virtual Doctor Visit |
| Behavioral health | $14 copay in office $14 copay for Virtual Behavioral Health Visit |
| Urgent care | $24 copay |
| Emergency | $80 copay |
| Hospital services (inpatient) | $0 copay |
| Hospital services (outpatient) | $0 copay |
| Diabetic supplies and monitors | In-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: $3 copay Tier 2* Preferred Brand – up to 30-day supply: $23 copay Tier 3 Non-Preferred Brand – up to 30-day supply: $53 copay Tier 4 Specialty Tier – up to 30-day supply: $53 copay |
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Group retiree benefits for SEIB
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IMPORTANT DATES
2022 Open Enrollment Period
Begins: 11/1/2021
Ends: 11/30/2021
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