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

Plan I - 13651

Plan II - 13650

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	UnitedHealthcare® Group Medicare Advantage (PPO) – Plan I - 13651	UnitedHealthcare® Group Medicare Advantage (PPO) – Plan II - 13650
UnitedHealthcare® Group Medicare Advantage (PPO) – Plan I - 13651	UnitedHealthcare® Group Medicare Advantage (PPO) – Plan II - 13650
Annual medical deductible	$0	$0
Annual medical deductible
$0	$0
Annual medical out-of-pocket maximum	$2, 500	$2, 800
Annual medical out-of-pocket maximum
$2, 500	$2, 800
Office and clinic visits	$5 copay for primary care $25 copay for specialist visit	$5 copay for primary care $25 copay for specialist visit
Office and clinic visits
$5 copay for primary care $25 copay for specialist visit	$5 copay for primary care $25 copay for specialist visit
Hospital services (inpatient)	$250 copay per stay	$250 copay per stay
Hospital services (inpatient)
$250 copay per stay	$250 copay per stay
Hospital services (outpatient)	$100 copay	$100 copay
Hospital services (outpatient)
$100 copay	$100 copay
Prescription drug coverage	Retail Tier 1: $15 copay Tier 2: $35 copay Tier 3: $70 copay Tier 4: $70 copay Mail Order Tier 1: $30 copay Tier 2: $70 copay Tier 3: $140 copay Tier 4: $140 copay The UnitedHealthcare Group Medicare Advantage PPO Plan I offers additional coverage during the Coverage Gap stage of the Prescription Drug Plan. After your total drug costs reach $5,030, the plan continues to pay its share of the cost of your drugs and you pay your share of the cost (your copay) until you reach the Catastrophic Coverage stage. Please see Plan Guide for details.	Retail Tier 1: $10 copay Tier 2: $20 copay Tier 3: $35 copay Tier 4: $35 copay Mail Order Tier 1: $20 copay Tier 2: $40 copay Tier 3: $70 copay Tier 4: $70 copay The UnitedHealthcare Group Medicare Advantage PPO Plan II offers standard coverage during the Coverage Gap stage of the Prescription Drug Plan. After your total drug costs reach $5,030, you pay 25% of the price for brand name and generic drugs until you reach the Catastrophic Coverage stage. Please see Plan Guide for details.
Prescription drug coverage
Retail Tier 1: $15 copay Tier 2: $35 copay Tier 3: $70 copay Tier 4: $70 copay Mail Order Tier 1: $30 copay Tier 2: $70 copay Tier 3: $140 copay Tier 4: $140 copay The UnitedHealthcare Group Medicare Advantage PPO Plan I offers additional coverage during the Coverage Gap stage of the Prescription Drug Plan. After your total drug costs reach $5,030, the plan continues to pay its share of the cost of your drugs and you pay your share of the cost (your copay) until you reach the Catastrophic Coverage stage. Please see Plan Guide for details.	Retail Tier 1: $10 copay Tier 2: $20 copay Tier 3: $35 copay Tier 4: $35 copay Mail Order Tier 1: $20 copay Tier 2: $40 copay Tier 3: $70 copay Tier 4: $70 copay The UnitedHealthcare Group Medicare Advantage PPO Plan II offers standard coverage during the Coverage Gap stage of the Prescription Drug Plan. After your total drug costs reach $5,030, you pay 25% of the price for brand name and generic drugs until you reach the Catastrophic Coverage stage. Please see Plan Guide for details.

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.