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

SAMBA High Option

Summary of benefits (pdf)

SAMBA Standard Option

Summary of benefits (pdf)

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 information about these preventive services, please call the Customer Service number on your member ID card.

Benefits and costs

Plan options 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): 100% Class 2 Minor: 80% Class 3 Major: 50% 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): 100% Class 2 Minor: 80% Class 3 Major: 50% 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): 100% Class 2 Minor: 80% Class 3 Major: 50% 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): 100% Class 2 Minor: 80% Class 3 Major: 50% 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. Estimate Drug Cost	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. Estimate Drug Cost
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. Estimate Drug Cost	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. Estimate Drug Cost
Annual prescription (Part D) out-of-pocket maximum	$5,000	$6,000
Annual prescription (Part D) out-of-pocket maximum
$5,000	$6,000

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.