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

Standard and Premium plan

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) Standard Plan	UnitedHealthcare ® Group Medicare Advantage (PPO) Premium Plan
UnitedHealthcare® Group Medicare Advantage (PPO) Standard Plan	UnitedHealthcare ® Group Medicare Advantage (PPO) Premium Plan
Annual medical deductible	None	None
Annual medical deductible
None	None
Annual out-of-pocket maximum	$3, 500	$2, 500
Annual out-of-pocket maximum
$3, 500	$2, 500
Office and clinic visits	$25 copay primary care $30 copay specialist visit	$15 copay primary care $25 copay specialist visit
Office and clinic visits
$25 copay primary care $30 copay specialist visit	$15 copay primary care $25 copay specialist visit
Hospital services ( inpatient)	20% coinsurance per admit	20% coinsurance per admit
Hospital services ( inpatient)
20% coinsurance per admit	20% coinsurance per admit
Hospital services (outpatient)	$95 copay (observation room) $25 copay (PCP) $30 copay (SPC)	$50 copay (observation room) $15 copay (PCP) $25 copay (SPC)
Hospital services (outpatient)
$95 copay (observation room) $25 copay (PCP) $30 copay (SPC)	$50 copay (observation room) $15 copay (PCP) $25 copay (SPC)
Urgent care	$25 copay	$20 copay
Urgent care
$25 copay	$20 copay
Emergency	$50 copay	$50 copay
Emergency
$50 copay	$50 copay
Prescription drug coverage	Tier 1 $0 copay select generic drugs $15 copay (31-day retail) $37.50 copay (retail and mail order 100 days) Tier 2 $45 copay (31-day retail) $112.50 copay (retail and mail order 100 days) Tier 3 $85 copay (31-day retail) $212.50 copay (retail and mail order 100 days) Tier 4 $85 copay (31-day retail) $212.50 copay (retail and mail order 100 days)	Tier 1 $0 copay select generic drugs $15 copay (31-day retail) $37.50 copay (retail and mail order 100 days) Tier 2 $45 copay (31-day retail) $112.50 copay (retail and mail order 100 days) Tier 3 $85 copay (31-day retail) $212.50 copay (retail and mail order 100 days) Tier 4 $85 copay (31-day retail) $212.50 copay (retail and mail order 100 days)
Prescription drug coverage
Tier 1 $0 copay select generic drugs $15 copay (31-day retail) $37.50 copay (retail and mail order 100 days) Tier 2 $45 copay (31-day retail) $112.50 copay (retail and mail order 100 days) Tier 3 $85 copay (31-day retail) $212.50 copay (retail and mail order 100 days) Tier 4 $85 copay (31-day retail) $212.50 copay (retail and mail order 100 days)	Tier 1 $0 copay select generic drugs $15 copay (31-day retail) $37.50 copay (retail and mail order 100 days) Tier 2 $45 copay (31-day retail) $112.50 copay (retail and mail order 100 days) Tier 3 $85 copay (31-day retail) $212.50 copay (retail and mail order 100 days) Tier 4 $85 copay (31-day retail) $212.50 copay (retail and mail order 100 days)

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.