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 (HMO)

2025 materials

ASRS

Spanish

  • Plan Guide Spanish - Coming soon

PSPRS

Spanish

  • Plan Guide Spanish - Coming soon

UnitedHealthcare® Group Medicare Advantage (PPO)

2025 materials

ASRS

Spanish

  • Plan Guide Spanish - Coming soon

PSPRS

Spanish

  • Plan Guide Spanish - Coming soon

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

Benefits and costs
Benefit UnitedHealthcare® Group Medicare Advantage (HMO) UnitedHealthcare® Group Medicare Advantage (PPO)
Annual medical deductible $300 None
Annual out-of-pocket maximum $4,250 $5,000
Office and clinic visits $15 copay for primary care
$50 copay for specialist visit		 $15 copay for primary care
$25 copay for specialist visit
Hospital services (inpatient) $200 copay per admission $100 copay per admission
Hospital emergency services (outpatient)

$150 copay for each Medicare-covered emergency room visit (waived if admitted)

$75 copay for each Medicare-covered urgently needed care visit

$50 copay for each Medicare-covered emergency room visit (waived if admitted)

$25 copay for each Medicare-covered urgently needed care visit
Annual prescription drug deductible $300 None
Prescription drug coverage

Retail (30-day supply)

Tier 1: $10 copay
Tier 2: $40 copay
Tier 3: $80 copay
Tier 4: $80 copay

Mail order (90-day supply)

Tier 1: $20 copay
Tier 2: $80 copay
Tier 3: $160 copay
Tier 4: $160 copay

The UnitedHealthcare® Group Medicare Advantage HMO plan has a $300 Prescription Drug Deductible. After your deductible is met, you move into the Initial Coverage Stage where you’ll pay a copay for covered drugs based on the tier of the medication. After you and others on your behalf have paid a combined total of $2,000 for your prescription drugs, you will pay $0 for Medicare Part D covered drugs for the rest of the plan year. Please see Plan Guide for details.

Retail (30-day supply)

Tier 1: $10 copay
Tier 2: $35 copay
Tier 3: $35 copay
Tier 4: $35 copay

Mail order (90-day supply)

Tier 1: $20 copay
Tier 2: $70 copay
Tier 3: $70 copay
Tier 4: $70 copay

The UnitedHealthcare® Group Medicare Advantage PPO plan has no Prescription Drug Deductible. You’ll start out in the Initial Coverage Stage where you’ll pay a copay for covered drugs based on the tier of the medication. After you and others on your behalf have paid a combined total of $2,000 for your prescription drugs, you will pay $0 for Medicare Part D covered drugs for the rest of the plan year. Please see Plan Guide for details.

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 cost sharing that applies to out-of-network services.