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 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, no matter what cost-sharing tier it’s on. You may pay less depending on your plan coverage. Refer to your plan materials.

 

2023 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

Benefits & costs
Benefits GMA Comprehensive (PPO) GMA Premium (PPO)
Annual medical deductible None None
Annual out-of-pocket maximum $2,000 $1,500
Office and clinic visits $5 copay $5 copay
Hospital services (inpatient) $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

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.