Washington State PEBB – Review plan benefits
UnitedHealthcare®
text size

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 (PPO) 

file
file
file
file
Benefits and costs UnitedHealthcare PEBB Balance (PPO) UnitedHealthcare PEBB Complete (PPO)
Annual medical deductible $0 $0
Annual out-of-pocket maximum $2,000 $500
Office and clinic visits

$15 copay primary care

$30 copay specialist

$0 copay primary care

$0 copay specialist

Hospital services (inpatient) $500 per admit $0
Hospital services (outpatient) $250 copay $0
Prescription drug coverage

Out of pocket maximum:  $2,000

Deductible: $100 (applies to Tiers 2, 3, & 4 only)

Preventative/ACA List: $0, deductible does not apply

Preferred Insulin List: 5% coinsurance with $10 maximum, deductible does not apply

Foreign Rx claims: 30% copay with $47 maximum after deductible


Retail (30-day supply)

Tier 1: 10% coinsurance with $25 maximum, deductible does not apply

Tier 2: 30% coinsurance with $47 maximum, after deductible

Tier 3: 50% coinsurance after deductible

Tier 4: 50% coinsurance with $100 maximum, after deductible


Mail Order (90-day supply for Tiers 1, 2, and 3)

Tier 1: 10% coinsurance with $75 maximum, deductible does not apply

Tier 2: 30% coinsurance with $141 maximum, after deductible

Tier 3: 50% coinsurance after deductible

Tier 4: 50% coinsurance with $100 maximum, after deductible (limited to 30-day supply)

Out of pocket maximum:  $2,000

Deductible: $100 (applies to Tiers 2, 3, & 4 only)

Preventative/ACA List: $0, deductible does not apply

Preferred Insulin List: 5% coinsurance with $10 maximum, deductible does not apply

Foreign Rx claims: 30% copay with $47 maximum after deductible


Retail (30-day supply)

Tier 1: 10% coinsurance with $25 maximum, deductible does not apply

Tier 2: 30% coinsurance with $47 maximum, after deductible

Tier 3: 50% coinsurance after deductible

Tier 4: 50% coinsurance with $100 maximum, after deductible


Mail Order (90-day supply for Tiers 1, 2, and 3)

Tier 1: 10% coinsurance with $75 maximum, deductible does not apply

Tier 2: 30% coinsurance with $141 maximum, after deductible

Tier 3: 50% coinsurance after deductible

Tier 4: 50% coinsurance with $100 maximum, after deductible (limited to 30-day supply)

Already a member?

file

New user? Register now

Questions? We're here to help.
Contact us   

file
Washington State Public Employees Benefits Board

Group retiree benefits for the Washington State Public Employees Benefits Board (PEBB) Program

This is not my group.
Back to uhcretiree.com »

IMPORTANT DATES


2021 Open Enrollment Period

Began: 11/01/20
Ended: 11/30/20

 

 

file

Virtual Education Center 

 

It’s all the information you need to help you understand and access your MAPD plan benefits — in one place, at any time, from your favorite device. Let's get started. »

PDF (Portable Document Format) files can be viewed with Adobe® Reader®. If you don’t already have this viewer on your computer, download it free from the Adobe Web site.

Last updated: 04.20.2021 at 12:01 AM CT  H2001_020821AMR