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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)
2024 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.
Benefits and costs
| Benefits |
Local Government Health and Wellness Medicare Advantage Plan (PPO) |
|---|---|
|
Local Government Health and Wellness Medicare Advantage Plan (PPO) |
|
| Annual medical deductible |
$0 |
| Annual medical deductible | |
|
$0 |
|
| Annual out-of-pocket maximum |
$6,700 |
| Annual out-of-pocket maximum | |
|
$6,700 |
|
| Office and clinic visits |
$20 copay for primary care $30 copay for specialist visit $0 copay for Virtual Doctor Visit |
| Office and clinic visits | |
|
$20 copay for primary care $30 copay for specialist visit $0 copay for Virtual Doctor Visit |
|
| Behavioral health |
$20 copay in office $20 copay for Virtual Behavioral Health Visit |
| Behavioral health | |
|
$20 copay in office $20 copay for Virtual Behavioral Health Visit |
|
| Urgent care |
$30 copay |
| Urgent care | |
|
$30 copay |
|
| Emergency |
$80 copay |
| Emergency | |
|
$80 copay |
|
| Hospital services (inpatient) |
$200 copay day 1 $50 copay days 2-5 $0 copay days 6-Unlimited |
| Hospital services (inpatient) | |
|
$200 copay day 1 $50 copay days 2-5 $0 copay days 6-Unlimited |
|
| Hospital services (outpatient) |
$0 copay |
| Hospital services (outpatient) | |
|
$0 copay |
|
| Hospital services (outpatient) |
$0 copay |
| Hospital services (outpatient) | |
|
$0 copay |
|
| Diabetic supplies and monitors |
In-network: $0 copay Out-of-network: $0 copay For diabetes monitoring supplies, the plan covers the following brands of blood glucose monitors and test strips: OneTouch® Ultra® 2, OneTouch® Verio™, OneTouch® UltraMini™, ACCU-CHEK® Aviva, ACCU-CHEK® Compact, ACCU-CHEK® SmartView. Other brands are not covered by our plan. If you use a brand of supplies that is not covered by our plan, you should speak with your doctor to get a new prescription for a covered brand. |
| Diabetic supplies and monitors | |
|
In-network: $0 copay Out-of-network: $0 copay For diabetes monitoring supplies, the plan covers the following brands of blood glucose monitors and test strips: OneTouch® Ultra® 2, OneTouch® Verio™, OneTouch® UltraMini™, ACCU-CHEK® Aviva, ACCU-CHEK® Compact, ACCU-CHEK® SmartView. Other brands are not covered by our plan. If you use a brand of supplies that is not covered by our plan, you should speak with your doctor to get a new prescription for a covered brand. |
|
| Prescription drug coverage |
Tier 1 Generic – up to 30-day supply: $10 copay; up to 100-day supply: $20 copay Tier 2* Preferred Brand – up to 100-day supply: 20% coinsurance Tier 3* Non-Preferred Brand – up to 100-day supply: 20% coinsurance Tier 4* Specialty Tier – up to 100-day supply: 20% coinsurance
*For Tiers 2, 3 & 4 there is a $100 deductible before your coinsurance begins |
| Prescription drug coverage | |
|
Tier 1 Generic – up to 30-day supply: $10 copay; up to 100-day supply: $20 copay Tier 2* Preferred Brand – up to 100-day supply: 20% coinsurance Tier 3* Non-Preferred Brand – up to 100-day supply: 20% coinsurance Tier 4* Specialty Tier – up to 100-day supply: 20% coinsurance
*For Tiers 2, 3 & 4 there is a $100 deductible before your coinsurance begins |
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.