Coverage and benefits

Get a quick overview of your plan benefits and costs and find more detailed information about additional benefits and programs.

UnitedHealthcare® Medicare Advantage (PPO)

2022 materials

Benefits and costs

Benefits and costs
Benefit	UnitedHealthcare® Medicare Advantage (PPO)
Part B premium subsidy	$50 per month
Annual medical deductible	None
Annual out-of-pocket maximum	None
Office and clinic visits	$0 copay for primary care, specialist visits or virtual visits/telemedicine
Hospital services (inpatient)	$0 copay
Hospital services (outpatient)	$0 copay
Ambulance services	$0 copay
Emergency room	$0 copay
Urgent care	$0 copay
Durable medical equipment	$0 copay
Prosthetics	$0 copay
Diabetic Supplies (test strips, lancets, glucose monitors)	$0 copay
Preventive services	$0 copay
Routine podiatry	$0 copay – 6 per year
Hearing aid allowance	$0 copay $1,500 allowance for unlimited aids every 3 years. Allowance is combined for both ears. Hearing aids ordered through providers other than UnitedHealthcare Hearing are not covered.
Dental	Class 1 Preventive & Diagnostic (P&D)	100%
	Class 2 Minor	80%
	Class 3 Major	50%
	Deductible (P&D not included)	$50
	Annual Calendar Maximum	$1,000
	Out-of-Network Reimbursement Schedule	Maximum Allowable Charge
	Note: preventive and diagnostic services do not apply to the annual maximum.
Prescription drug coverage	Retail (Note: 90-day retail supply is available for 3x copay amount) Tier 1 (Generic): $10 copay Tier 2 (Preferred Brand): $30 copay Tier 3 (Non-Preferred Brand): $45 copay Tier 4 (Specialty Tier): $60 copay Generic oral diabetic medications: $0 copay Mail Order (up to 90-day supply) Tier 1 (Generic): $20 copay Tier 2 (Preferred Brand): $60 copay Tier 3 (Non-Preferred Brand): $90 copay Tier 4 (Specialty Tier): $120 copay

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.

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.