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)

2025 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: $5 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: $10 copay Tier 2 – preferred brand: $50 copay Tier 3 – non-preferred brand: $120 copay Tier 4 – specialty tier: $180 copay
Prescription drug coverage
Retail Tier 1 – generic: $5 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: $10 copay Tier 2 – preferred brand: $50 copay Tier 3 – non-preferred brand: $120 copay Tier 4 – specialty tier: $180 copay
Annual prescription (Part D) out-of-pocket maximum	$2,000 Once your True Out of Pocket (TROOP) reaches $2,000 you enter the Catastrophic Coverage level and will have no copay for all covered medications.
Annual prescription (Part D) out-of-pocket maximum
$2,000 Once your True Out of Pocket (TROOP) reaches $2,000 you enter the Catastrophic Coverage level and will have no copay for all covered 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 UCard.