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 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, no matter what cost-sharing tier it’s on. You may pay less depending on your plan coverage. Refer to your plan materials.


UnitedHealthcare® Group Medicare Advantage (PPO)

2023 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

Benefits and costs
Benefit UnitedHealthcare® Group Medicare Advantage (PPO)
Annual medical deductible $0 
Annual out-of-pocket maximum $6,700
Office and clinic visits $10 copay for primary care
$15 copay for specialist visit
$0 copay for Virtual Doctor Visit
Behavioral health $14 copay in office
$14 copay for Virtual Behavioral Health Visit
Urgent care $24 copay
Emergency $80 copay
Hospital services (inpatient) $0 copay
Hospital services (outpatient) $0 copay 
Diabetic supplies and monitors

In-network: $0 copay
Out-of-network: $0 copay

For diabetes monitoring supplies, the plan covers the following brands of blood glucose monitors and test strips: <OneTouch® Ultra® 2, OneTouch® Verio™, OneTouch® UltraMini™, ACCU-CHEK® Aviva, ACCU-CHEK® Compact, ACCU-CHEK® SmartView>. Other brands are not covered by our plan.

If you use a brand of supplies that is not covered by our plan, you should speak with your doctor to get a new prescription for a covered brand.

Prescription drug coverage Tier 1 Generic – up to 30-day supply: $3 copay
Tier 2 Preferred Brand – up to 30-day supply: $23 copay
Tier 3 Non-Preferred Brand – up to 30-day supply: $53 copay
Tier 4 Specialty Tier – up to 30-day supply: $53 copay


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.