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) - Group 13694

2024 materials

Group 13694

UnitedHealthcare® Group Medicare Advantage (PPO) - Group 12786

2024 materials

Group 12786

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 and costs

UnitedHealthcare® Group Medicare Advantage (PPO)

UnitedHealthcare® Group Medicare Advantage (PPO)
Annual medical deductible

$0
Annual medical deductible

$0
Annual out-of-pocket maximum

$3, 750 per person
Annual out-of-pocket maximum

$3, 750 per person
Office and clinic visits

$5 copay for primary care

$15 copay for specialist visit
Office and clinic visits

$5 copay for primary care

$15 copay for specialist visit
Hospital services (inpatient)

$150 copay per admission
Hospital services (inpatient)

$150 copay per admission
Hospital emergency services (outpatient)

$100 copay
Hospital emergency services (outpatient)

$100 copay
Urgent care

$20 copay

Waived if admitted to the hospital wihtin 24 hours of the same condition
Urgent care

$20 copay

Waived if admitted to the hospital wihtin 24 hours of the same condition
Prescription drug coverage

Retail (30-day supply)
Tier 1: $5 copay
Tier 2: $20 copay
Tier 3: $45 copy
Tier 4: $20 copay

Mail Order (90-day supply)
Tier 1: $10 copay
Tier 2: $40 copay
Tier 3: $90 copay
Tier 4: $40 copay
Prescription drug coverage

Retail (30-day supply)
Tier 1: $5 copay
Tier 2: $20 copay
Tier 3: $45 copy
Tier 4: $20 copay

Mail Order (90-day supply)
Tier 1: $10 copay
Tier 2: $40 copay
Tier 3: $90 copay
Tier 4: $40 copay

Important Notice

UHC Medicare SFHSS Important Notice

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.