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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)
2025 materials
SAMBA High Option
SAMBA Standard Option
Benefits and costs
| Benefits |
SAMBA High Option (PPO) |
SAMBA Standard Option (PPO) |
|---|---|---|
|
SAMBA High Option (PPO) |
SAMBA Standard Option (PPO) |
|
| Part B premium subsidy |
$100 |
$75 |
| Part B premium subsidy | ||
|
$100 |
$75 |
|
| Annual medical deductible |
None |
None |
| Annual medical deductible | ||
|
None |
None |
|
| Annual out-of-pocket maximum |
None |
None |
| Annual out-of-pocket maximum | ||
|
None |
None |
|
| Office and clinic visits |
$0 copay primary care office visit $0 copay specialist office visit $0 copay virtual visit and telemedicine |
$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 |
$0 copay primary care office visit $0 copay specialist office visit $0 copay virtual visit and telemedicine |
|
| Hospital services (inpatient) |
$0 copay |
$0 copay |
| Hospital services (inpatient) | ||
|
$0 copay |
$0 copay |
|
| Hospital services (outpatient) |
$0 copay |
$0 copay |
| Hospital services (outpatient) | ||
|
$0 copay |
$0 copay |
|
| Ambulance services |
$0 copay |
$0 copay |
| Ambulance services | ||
|
$0 copay |
$0 copay |
|
| Emergency room |
$0 copay |
$0 copay |
| Emergency room | ||
|
$0 copay |
$0 copay |
|
| Urgent care |
$0 copay |
$0 copay |
| Urgent care | ||
|
$0 copay |
$0 copay |
|
| Durable medical equipment |
$0 copay |
$0 copay |
| Durable medical equipment | ||
|
$0 copay |
$0 copay |
|
| Prosthetics |
$0 copay |
$0 copay |
| Prosthetics | ||
|
$0 copay |
$0 copay |
|
| Diabetic supplies (test strips, lancets, glucose monitors) |
$0 copay |
$0 copay |
| Diabetic supplies (test strips, lancets, glucose monitors) | ||
|
$0 copay |
$0 copay |
|
| Preventive services |
$0 copay |
$0 copay |
| Preventive services | ||
|
$0 copay |
$0 copay |
|
| Routine podiatry |
6 per year / $0 copay |
6 per year / $0 copay |
| Routine podiatry | ||
|
6 per year / $0 copay |
6 per year / $0 copay |
|
| Acupuncture |
26 per year / $0 copay |
26 per year / $0 copay |
| Acupuncture | ||
|
26 per year / $0 copay |
26 per year / $0 copay |
|
| Chiropractic |
30 per year / $0 copay |
20 per year / $0 copay |
| Chiropractic | ||
|
30 per year / $0 copay |
20 per year / $0 copay |
|
| Rehabilitation therapies - physical therapy, speech therapy, occupational therapy |
$0 copay |
$0 copay |
| Rehabilitation therapies - physical therapy, speech therapy, occupational therapy | ||
|
$0 copay |
$0 copay |
|
| Hearing aid allowance - $1,000 allowance for unlimited aids every 3 years. Allowance is combined for both ears |
$0 copay
You must use a UnitedHealthcare Hearing provider to utilize the hearing aid allowance. |
$0 copay
You must use a UnitedHealthcare Hearing provider to utilize the hearing aid allowance. |
| Hearing aid allowance - $1,000 allowance for unlimited aids every 3 years. Allowance is combined for both ears | ||
|
$0 copay
You must use a UnitedHealthcare Hearing provider to utilize the hearing aid allowance. |
$0 copay
You must use a UnitedHealthcare Hearing provider to utilize the hearing aid allowance. |
|
| Dental |
Class 1 Preventive & Diagnostic (P&D): $0 copay Class 2 Minor: 80% coverage Class 3 Major: 50% coverage Deductible (P&D not included): $50 Annual Calendar Maximum: $1,000 Out-of-Network Reimbursement Schedule: Maximum Allowable Charge |
Class 1 Preventive & Diagnostic (P&D): $0 copay Class 2 Minor: 80% coverage Class 3 Major: 50% coverage Deductible (P&D not included): $50 Annual Calendar Maximum: $1,000 Out-of-Network Reimbursement Schedule: Maximum Allowable Charge |
| Dental | ||
|
Class 1 Preventive & Diagnostic (P&D): $0 copay Class 2 Minor: 80% coverage Class 3 Major: 50% coverage Deductible (P&D not included): $50 Annual Calendar Maximum: $1,000 Out-of-Network Reimbursement Schedule: Maximum Allowable Charge |
Class 1 Preventive & Diagnostic (P&D): $0 copay Class 2 Minor: 80% coverage Class 3 Major: 50% coverage Deductible (P&D not included): $50 Annual Calendar Maximum: $1,000 Out-of-Network Reimbursement Schedule: Maximum Allowable Charge |
|
| Vision |
Routine Eye Exam Refraction: $0 copay – 1 per 12 months Eyeglasses Allowance: $200 every 12 months Contact Lens Allowance (in lieu of glasses): $200 every 12 months |
Routine Eye Exam Refraction: $0 copay – 1 per 12 months Eyeglasses Allowance: $200 every 12 months Contact Lens Allowance (in lieu of glasses): $200 every 12 months |
| Vision | ||
|
Routine Eye Exam Refraction: $0 copay – 1 per 12 months Eyeglasses Allowance: $200 every 12 months Contact Lens Allowance (in lieu of glasses): $200 every 12 months |
Routine Eye Exam Refraction: $0 copay – 1 per 12 months Eyeglasses Allowance: $200 every 12 months Contact Lens Allowance (in lieu of glasses): $200 every 12 months |
|
| Prescription drug coverage |
Part D Retail (Up to a 30-day supply) Note: 90-day Retail supply for Tiers 1-3 is available for the same copay/coinsurance amount as Mail Order; Tier 4 is limited to a 30-day supply Tier 1 – generic: $5 copay Tier 2 – preferred brand: $30 copay Tier 3 – non-preferred brand: $75 copay Tier 4 – specialty tier: $110 copay
Part D Preferred Mail Order* (up to a 90-day supply for Tiers 1-3; Tier 4 is limited to a 30-day supply) Tier 1 – generic: $10 copay Tier 2 – preferred brand: $60 copay Tier 3 – non-preferred brand: $150 copay Tier 4 – specialty tier: $110 copay
* UnitedHealthcare’s pharmacy benefit manager is Optum Rx. Mail order prescriptions will be through Optum Rx. |
Part D Retail (Up to a 30-day supply) Note: 90-day Retail supply for Tiers 1-3 is available for the same copay/coinsurance amount as Mail Order; Tier 4 is limited to a 30-day supply Tier 1 – generic: $7 copay Tier 2 – preferred brand: $35 copay Tier 3 – non-preferred brand: $80 copay Tier 4 – specialty tier: $120 copay
Part D Preferred Mail Order* (up to a 90-day supply for Tiers 1-3; Tier 4 is limited to a 30-day supply) Tier 1 – generic: $15 copay Tier 2 – preferred brand: $70 copay Tier 3 – non-preferred brand: $160 copay Tier 4 – specialty tier: $120 copay
* UnitedHealthcare’s pharmacy benefit manager is Optum Rx. Mail order prescriptions will be through Optum Rx. |
| Prescription drug coverage | ||
|
Part D Retail (Up to a 30-day supply) Note: 90-day Retail supply for Tiers 1-3 is available for the same copay/coinsurance amount as Mail Order; Tier 4 is limited to a 30-day supply Tier 1 – generic: $5 copay Tier 2 – preferred brand: $30 copay Tier 3 – non-preferred brand: $75 copay Tier 4 – specialty tier: $110 copay
Part D Preferred Mail Order* (up to a 90-day supply for Tiers 1-3; Tier 4 is limited to a 30-day supply) Tier 1 – generic: $10 copay Tier 2 – preferred brand: $60 copay Tier 3 – non-preferred brand: $150 copay Tier 4 – specialty tier: $110 copay
* UnitedHealthcare’s pharmacy benefit manager is Optum Rx. Mail order prescriptions will be through Optum Rx. |
Part D Retail (Up to a 30-day supply) Note: 90-day Retail supply for Tiers 1-3 is available for the same copay/coinsurance amount as Mail Order; Tier 4 is limited to a 30-day supply Tier 1 – generic: $7 copay Tier 2 – preferred brand: $35 copay Tier 3 – non-preferred brand: $80 copay Tier 4 – specialty tier: $120 copay
Part D Preferred Mail Order* (up to a 90-day supply for Tiers 1-3; Tier 4 is limited to a 30-day supply) Tier 1 – generic: $15 copay Tier 2 – preferred brand: $70 copay Tier 3 – non-preferred brand: $160 copay Tier 4 – specialty tier: $120 copay
* UnitedHealthcare’s pharmacy benefit manager is Optum Rx. Mail order prescriptions will be through Optum Rx. |
|
| 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 |
$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 |
| 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 |
$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 |
|
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.
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.
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.