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.

2024 materials

UnitedHealthcare® Group Medicare Advantage Prescription Drug (PPO)

UnitedHealthcare® Group Medicare Advantage Prescription Drug with Dental & Vision (PPO)

UnitedHealthcare® Group Medicare Advantage Edge (PPO)

For information on prescription benefits, please visit OptumRx.

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	UnitedHealthcare® Group Medicare Advantage Prescription Drug (PPO)	UnitedHealthcare® Group Medicare Advantage Edge (PPO)
UnitedHealthcare® Group Medicare Advantage Prescription Drug (PPO)	UnitedHealthcare® Group Medicare Advantage Edge (PPO)
Annual medical out-of-pocket maximum	$1,500 in-network	$1,500
Annual medical out-of-pocket maximum
$1,500 in-network	$1,500
Physician services	$10 copay primary care $10 copay specialist visit	$0 copay primary care $0 copay specialist visit
Physician services
$10 copay primary care $10 copay specialist visit	$0 copay primary care $0 copay specialist visit
Emergency room	$50 copy Waived if admitted to the hospital within 24 hours for the same condition.	$50 copy (worldwide)
Emergency room
$50 copy Waived if admitted to the hospital within 24 hours for the same condition.	$50 copy (worldwide)
Urgently needed care ( contracted providers)	$25 copy Waived if admitted to the hospital within 24 hours for the same condition.	$0 copay (worldwide)
Urgently needed care ( contracted providers)
$25 copy Waived if admitted to the hospital within 24 hours for the same condition.	$0 copay (worldwide)
Prescription drug coverage	Retail Tier 1: $5 copay Tier 2: $20 copay Tier 3: $50 copay Tier 4: $20 copay Mail Service Tier 1: $10 copay Tier 2: $40 copay Tier 3: $100 copay Tier 4: $40 copay	Optum Rx is the Pharmacy Benefit Manager (PBM) providing prescription benefits for this health plan.
Prescription drug coverage
Retail Tier 1: $5 copay Tier 2: $20 copay Tier 3: $50 copay Tier 4: $20 copay Mail Service Tier 1: $10 copay Tier 2: $40 copay Tier 3: $100 copay Tier 4: $40 copay	Optum Rx is the Pharmacy Benefit Manager (PBM) providing prescription benefits for this health plan.
Rx Maximum Out of Pocket	$7,400	$7,400
Rx Maximum Out of Pocket
$7,400	$7,400
Rx Deductible	$0	$0
Rx Deductible
$0	$0

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.