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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 (PPO)
2025 materials
Standard 80/20
Low 80/20
High 90/10
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
| Benefit | UnitedHealthcare® MAPD PPO – Standard 80/20 | UnitedHealthcare® MAPD PPO – Low 80/20 | UnitedHealthcare® MAPD PPO – High 90/10- grandfathered plan, available only to select group of retirees |
|---|---|---|---|
| Annual medical deductible | $150 | $350 | $0 |
| Annual out-of-pocket maximum | $2,400 | $4,000 | $1,650 |
| Office and clinic visits | $20 copay | $20 copay | $20 copay |
| Specialty office visits | $40 copay | $40 copay | $40 copay |
| Emergency room | $90 copay | $90 copay | $90 copay |
| Urgent care | $65 copay | $60 copay | $65 copay |
| Hospital services (inpatient) | $230 days 1-7, $0 days 8 + | $230 days 1-7, $0 days 8 + | $230 days 1-7, $0 days 8 + |
| Hospital services (outpatient) | 20% coinsurance | 20% coinsurance | 10% coinsurance |
| Prescription drug coverage | Retail Tier 1 Generic: 10% coinsurance to $16
Tier 2 Preferred brand: 20% coinsurance to $85 Tier 3 Non-preferred brand: 40% coinsurance to $170 Tier 4 Specialty: 33% coinsurance to $170
Note: 90-day retail supply is available for 3x copay amount. Mail Order available please see Plan Guide for details. Note: You won’t pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier. |
Retail Tier 1 Generic: 25% coinsurance to $26
Tier 2 Preferred brand: 25% coinsurance to $70 Tier 3 Non-preferred brand: 50% coinsurance to $130 Tier 4 Specialty: 33% coinsurance to $130
Note: 90-day retail supply is available for 3x copay amount. Mail Order available please see Plan Guide for details. Note: You won’t pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier. |
Retail Tier 1 Generic: 10% coinsurance to $16
Tier 2 Preferred brand: 20% coinsurance to $85 Tier 3 Non-preferred brand: 40% coinsurance to $170 Tier 4 Specialty: 33% coinsurance to $170
Note: 90-day retail supply is available for 3x copay Note: You won’t pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier. |
| Rx Deductible | $590 |
$590 |
$590 except for covered insulin products and most adult Part D vaccines
|
| Rx Maximum Out of pocket | $2,000 | $2,000 | $2,000 |
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.