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

Plan materials have been updated as of 3/9/2023 to include the correct FirstLine Essentials phone number.

PEBB Complete plan

PEBB Balance 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

Benefits and costs
Benefit	UnitedHealthcare PEBB Balance (PPO)	UnitedHealthcare PEBB Complete (PPO)
Annual medical deductible	$0	$0
Annual out-of-pocket maximum	$2,000	$500
Office and clinic visits	$15 copay primary care $30 copay specialist	$0 copay primary care $0 copay specialist
Hospital services (inpatient)	$500 copay per admit	$0 copay
Hospital services (outpatient)	$250 copay	$0 copay
Prescription drug coverage	Out of pocket maximum: $2,000 Deductible: $100 (applies to Tiers 2, 3, & 4 only) Preventative/ACA List: $0, deductible does not apply Preferred Insulin List: up to a $10 copay, deductible does not apply Foreign Rx claims: up to a $45 copay after deductible Retail (30-day supply) Tier 1: up to a $5 copay Tier 2: up to a $45 copay after deductible Tier 3: up to a $100 copay after deductible Tier 4: up to a $100 copay after deductible Mail Order (90-day supply for Tiers 1, 2, and 3) Tier 1: up to a $10 copay, deductible does not apply Tier 2: up to a $90 copay, after deductible Tier 3: up to a $200 copay, after deductible Tier 4: up to a $100 copay, after deductible (limited to 30-day supply)	Out of pocket maximum: $2,000 Deductible: $100 (applies to Tiers 2, 3, & 4 only) Preventative/ACA List: $0, deductible does not apply Preferred Insulin List: up to a $10 copay, deductible does not apply Foreign Rx claims: up to a $45 copay after deductible Retail (30-day supply) Tier 1: up to a $5 copay Tier 2: up to a $45 copay after deductible Tier 3: up to a $100 copay after deductible Tier 4: up to a $100 copay after deductible Mail Order (90-day supply for Tiers 1, 2, and 3) Tier 1: up to a $10 copay, deductible does not apply Tier 2: up to a $90 copay, after deductible Tier 3: up to a $200 after deductible Tier 4: up to a $100 copay, after deductible (limited to 30-day supply)

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.