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.

 

LSU First Medicare Retiree (PPO) plan administered by UnitedHealthcare ®

2025 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

Plan options and costs
Benefits

LSU First Medicare Retiree (PPO) plan administered by UnitedHealthcare®

LSU First Medicare Retiree (PPO) plan administered by UnitedHealthcare®
Annual medical deductible

None
Annual medical deductible

None
Office and clinic visits

$0 copay
Office and clinic visits

$0 copay
Hospital services (inpatient)

$0 copay
Hospital services (inpatient)

$0 copay
Hospital services (outpatient)

$0 copay
Hospital services (outpatient)

$0 copay
Emergency room services

$50 copay
Emergency room services

$50 copay
Prescription drug coverage

Retail:

Tier 1 – Generic: $0 copay
Tier 2 – Preferred Brand: $40 copay
Tier 3 – Non-Preferred Brand: $70 copay
Tier 4 – Specialty:  $100 copay

Mail Order:

Tier 1 – Generic: $0 copay
Tier 2 – Preferred Brand: $120 copay
Tier 3 – Non-Preferred Brand: $210 copay
Tier 4 – Specialty:  $300 copay

After your total out-of-pocket costs reach $2,000, you enter the Catastrophic Coverage stage. During the Catastrophic Coverage stage, you pay $0 copay for Medicare-covered drugs.
Prescription drug coverage

Retail:

Tier 1 – Generic: $0 copay
Tier 2 – Preferred Brand: $40 copay
Tier 3 – Non-Preferred Brand: $70 copay
Tier 4 – Specialty:  $100 copay

Mail Order:

Tier 1 – Generic: $0 copay
Tier 2 – Preferred Brand: $120 copay
Tier 3 – Non-Preferred Brand: $210 copay
Tier 4 – Specialty:  $300 copay

After your total out-of-pocket costs reach $2,000, you enter the Catastrophic Coverage stage. During the Catastrophic Coverage stage, you pay $0 copay for Medicare-covered drugs.

Important 2025 changes explained

For 2025, all stand-alone Medicare prescription drug plans and Medicare Advantage plans with prescription drug coverage will be impacted by changes made by the federal government. This video provides an overview of those changes.

Learn more

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 cost sharing that applies to out-of-network services.