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

GMA Comprehensive (PPO)

GMA Premium (PPO)

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	GMA Comprehensive (PPO)	GMA Premium (PPO)
GMA Comprehensive (PPO)	GMA Premium (PPO)
Annual medical deductible	None	None
Annual medical deductible
None	None
Annual out-of-pocket maximum	$2,000	$1,500
Annual out-of-pocket maximum
$2,000	$1,500
Office and clinic visits	$5 copay	$5 copay
Office and clinic visits
$5 copay	$5 copay
Hospital services (inpatient)	$0 copay	$0 copay
Hospital services (inpatient)
$0 copay	$0 copay
Hospital services (outpatient)	$0 copay	$0 copay
Hospital services (outpatient)
$0 copay	$0 copay
Prescription drug coverage	Retail Tier 1: $10 copay Tier 2: $30 copay Tier 3: $50 copay Tier 4: $50 copay Mail Order Tier 1: $25 copay Tier 2: $70 copay Tier 3: $120 copay Tier 4: $120 copay	Retail Tier 1: $5 copay Tier 2: $25 copay Tier 3: $40 copay Tier 4: $40 copay Mail Order Tier 1: $12 copay Tier 2: $60 copay Tier 3: $100 copay Tier 4: $100 copay
Prescription drug coverage
Retail Tier 1: $10 copay Tier 2: $30 copay Tier 3: $50 copay Tier 4: $50 copay Mail Order Tier 1: $25 copay Tier 2: $70 copay Tier 3: $120 copay Tier 4: $120 copay	Retail Tier 1: $5 copay Tier 2: $25 copay Tier 3: $40 copay Tier 4: $40 copay Mail Order Tier 1: $12 copay Tier 2: $60 copay Tier 3: $100 copay Tier 4: $100 copay

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.