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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)
2024 materials
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 |
UnitedHealthcare PEBB Balance (PPO) |
UnitedHealthcare PEBB Complete (PPO) |
|---|---|---|
|
UnitedHealthcare PEBB Balance (PPO) |
UnitedHealthcare PEBB Complete (PPO) |
|
| Annual medical deductible |
$0 |
$0 |
| Annual medical deductible | ||
|
$0 |
$0 |
|
| Annual out-of-pocket maximum |
$2,000 |
$500 |
| 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 |
| 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 (inpatient) | ||
|
$500 copay per admit |
$0 copay |
|
| Hospital services (outpatient) |
$250 copay |
$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)
|
| 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)
|
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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.