Coverage and benefits

Get a quick overview of your plan benefits and costs and find more detailed information about additional benefits and programs.

UnitedHealthcare Retiree Advantage Plan (PPO)

2024 materials

Benefits and costs

Plan options and costs
Benefits

UnitedHealthcare Retiree Advantage Plan (PPO)

UnitedHealthcare Retiree Advantage Plan (PPO)
Part B premium reduction

$150 per month
Part B premium reduction

$150 per month
Annual medical deductible

None
Annual medical deductible

None
Annual out-of-pocket maximum

none
Annual out-of-pocket maximum

none
Office and clinic visits

$0 copay primary care office visit

$0 copay specialist office visit

$0 copay virtual visit and telemedicine
Office and clinic visits

$0 copay primary care office visit

$0 copay specialist office visit

$0 copay virtual visit and telemedicine
Hospital services ( inpatient)

$0 copay
Hospital services ( inpatient)

$0 copay
Hospital services (outpatient)

$0 copay
Hospital services (outpatient)

$0 copay
Ambulance services

$0 copay
Ambulance services

$0 copay
Emergency room

$0 copay
Emergency room

$0 copay
Urgent care

$0 copay
Urgent care

$0 copay
Durable medical equipment

$0 copay
Durable medical equipment

$0 copay
Prosthetics

$0 copay
Prosthetics

$0 copay
Diabetic supplies ( test strips, lancets, glucose monitors)

$0 copay
Diabetic supplies ( test strips, lancets, glucose monitors)

$0 copay
Preventive services

$0 copay
Preventive services

$0 copay
Routine podiatry - 6 per year

$0 copay
Routine podiatry - 6 per year

$0 copay
Acupuncture - 12 per year

$0 copay
Acupuncture - 12 per year

$0 copay
Chiropractic - 20 per year

$0 copay
Chiropractic - 20 per year

$0 copay
Rehabilitation therapies - physical, speech therapy, occupational therapy

$0 copay
Rehabilitation therapies - physical, speech therapy, occupational therapy

$0 copay
Hearing aid allowance - $1,500 allowance for unlimited aids every 3 years. Allowance is combined for both ears

$0 copay

You must call UnitedHealthcare Hearing in advance of using the hearing allowance and use a UnitedHealthcare Hearing provider.
Hearing aid allowance - $1,500 allowance for unlimited aids every 3 years. Allowance is combined for both ears

$0 copay

You must call UnitedHealthcare Hearing in advance of using the hearing allowance and use a UnitedHealthcare Hearing provider.
Dental coverage

$0 copay for preventive care services - oral exams, cleanings, bite wing xrays, sealants, and perio maintenenace.
$0 deductible
$500 annual maximum.

No coverage for basic, minor or major services.

* This plan is available to you through a standalone UnitedHealthcare Dental plan at no additional cost to you
Dental coverage

$0 copay for preventive care services - oral exams, cleanings, bite wing xrays, sealants, and perio maintenenace.
$0 deductible
$500 annual maximum.

No coverage for basic, minor or major services.

* This plan is available to you through a standalone UnitedHealthcare Dental plan at no additional cost to you
Prescription drug coverage

Retail

Tier 1 – generic: $6 copay
Tier 2 – preferred brand: $25 copay
Tier 3 – non-preferred brand: $60 copay
Tier 4 – specialty tier: $90 copay

Mail Order

Tier 1 – generic: $12 copay
Tier 2 – preferred brand: $50 copay
Tier 3 – non-preferred brand: $120 copay
Tier 4 – specialty tier: $180 copay

The UnitedHealthcare Group Medicare Advantage PPO Plan offers full coverage through the coverage gap (donut hole).  You will continue to pay your normal copays once you enter the donut hole.  Once your True Out of Pocket (TROOP) reaches $8,000 you enter the Catastrophic Coverage level and will have no copay for all medications
Prescription drug coverage

Retail

Tier 1 – generic: $6 copay
Tier 2 – preferred brand: $25 copay
Tier 3 – non-preferred brand: $60 copay
Tier 4 – specialty tier: $90 copay

Mail Order

Tier 1 – generic: $12 copay
Tier 2 – preferred brand: $50 copay
Tier 3 – non-preferred brand: $120 copay
Tier 4 – specialty tier: $180 copay

The UnitedHealthcare Group Medicare Advantage PPO Plan offers full coverage through the coverage gap (donut hole).  You will continue to pay your normal copays once you enter the donut hole.  Once your True Out of Pocket (TROOP) reaches $8,000 you enter the Catastrophic Coverage level and will have no copay for all medications

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.

 

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.