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 #1

Plan #2

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) #1	UnitedHealthcare Group Medicare Advantage (PPO) #2
UnitedHealthcare Group Medicare Advantage (PPO) #1	UnitedHealthcare Group Medicare Advantage (PPO) #2
Annual medical deductible	None	None
Annual medical deductible
None	None
Annual out-of-pocket maximum	$2, 000	$6, 000
Annual out-of-pocket maximum
$2, 000	$6, 000
Office and clinic visits	$0 copay primary care and specialist visit	$20 copay primary care $30 copay specialist visit
Office and clinic visits
$0 copay primary care and specialist visit	$20 copay primary care $30 copay specialist visit
Hospital services (inpatient)	$300 copay, maximum 3 times	$500 copay, maximum 3 times
Hospital services (inpatient)
$300 copay, maximum 3 times	$500 copay, maximum 3 times
Hospital services (outpatient)	$0 copay	$200 copay
Hospital services (outpatient)
$0 copay	$200 copay
Prescription drug coverage	Retail Tier 1: $15 copay Tier 2: $45 copay Tier 3: $60 copay Tier 4: $75 copay Mail Order Tier 1: $30 copay Tier 2: $90 copay Tier 3: $120 copay Tier 4: $75 copay (limited to 31-day supply)	Retail Tier 1: $15 copay Tier 2: $45 copay Tier 3: $60 copay Tier 4: $75 copay Mail Order Tier 1: $30 copay Tier 2: $90 copay Tier 3: $120 copay Tier 4: $75 copay (limited to 31-day supply)
Prescription drug coverage
Retail Tier 1: $15 copay Tier 2: $45 copay Tier 3: $60 copay Tier 4: $75 copay Mail Order Tier 1: $30 copay Tier 2: $90 copay Tier 3: $120 copay Tier 4: $75 copay (limited to 31-day supply)	Retail Tier 1: $15 copay Tier 2: $45 copay Tier 3: $60 copay Tier 4: $75 copay Mail Order Tier 1: $30 copay Tier 2: $90 copay Tier 3: $120 copay Tier 4: $75 copay (limited to 31-day supply)

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.