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

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)

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UnitedHealthcare® Group Medicare Advantage (PPO)

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Plan Premium

$134.94
Plan Premium

$134.94
Annual medical deductible

$0
Annual medical deductible

$0
Annual out-of-pocket maximum

$3,400
Annual out-of-pocket maximum

$3,400
Office and clinic visits

$15 copay for primary care
$45 copay for specialist visit
$0 copay for Virtual Doctor Visits using Doctor on Demand and AmWell
$15 copay using other in-network providers that have the ability and are qualified to offer virtual medical visits.
Office and clinic visits

$15 copay for primary care
$45 copay for specialist visit
$0 copay for Virtual Doctor Visits using Doctor on Demand and AmWell
$15 copay using other in-network providers that have the ability and are qualified to offer virtual medical visits.
Hospital services (inpatient)

$300 copay per day: days 1-9

$0 copay per day after that
Hospital services (inpatient)

$300 copay per day: days 1-9

$0 copay per day after that
Hospital emergency services ( outpatient)

$500 copay for outpatient surgery

$40 copay for outpatient rehabilitation ( physical, occupational, or speech/language therapy)
Hospital emergency services ( outpatient)

$500 copay for outpatient surgery

$40 copay for outpatient rehabilitation ( physical, occupational, or speech/language therapy)
Prescription drug coverage

Initial Coverage Stage

Network Pharmacy (30-day retail supply)
Tier 1: Preferred Generic $10 copay (up to 30-day)
Tier 2: Preferred Brand $40 copay
Tier 3: Non-preferred Drug $90 copay
Tier 4: Specialty Tier 33% coinsurance

Mail Service Pharmacy (90-day supply)
Tier 1: Preferred Generic $0 copay (31 to 90-day)
Tier 2: Preferred Brand $80 copay
Tier 3: Non-preferred Drug $180 copay
Tier 4: Specialty Tier 33% coinsurance

Coverage gap stage

The Coverage Gap, or donut hole", has been eliminated and your out of pocket limit (the amount you and others on your behalf pay) is $2,000. That means you're more protected from high drug costs in 2025.

Catastrophic coverage stage

Once you're in this stage, you won't pay anything for your Medicare-covered Part D drugs for the rest of the plan year.

If your plan includes additional prescription drug coverage, you will continue to pay the cost-sharing amounts from the Initial Coverage stage for those drugs. Please see your Additional Drug Coverage list for more information.
Prescription drug coverage

Initial Coverage Stage

Network Pharmacy (30-day retail supply)
Tier 1: Preferred Generic $10 copay (up to 30-day)
Tier 2: Preferred Brand $40 copay
Tier 3: Non-preferred Drug $90 copay
Tier 4: Specialty Tier 33% coinsurance

Mail Service Pharmacy (90-day supply)
Tier 1: Preferred Generic $0 copay (31 to 90-day)
Tier 2: Preferred Brand $80 copay
Tier 3: Non-preferred Drug $180 copay
Tier 4: Specialty Tier 33% coinsurance

Coverage gap stage

The Coverage Gap, or donut hole", has been eliminated and your out of pocket limit (the amount you and others on your behalf pay) is $2,000. That means you're more protected from high drug costs in 2025.

Catastrophic coverage stage

Once you're in this stage, you won't pay anything for your Medicare-covered Part D drugs for the rest of the plan year.

If your plan includes additional prescription drug coverage, you will continue to pay the cost-sharing amounts from the Initial Coverage stage for those drugs. Please see your Additional Drug Coverage list for more information.

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.

Learn more

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.