Coverage and benefits

Get a quick overview of your plan benefits and costs and find more detailed information about additional benefits and programs.

UnitedHealthcare® Group Medicare Advantage (PPO)

2023 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

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.