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2013 Medicare Advantage Plan Benefit Details for the UnitedHealthcare Dual Complete RP (Regional PPO SNP)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2013 Medicare Advantage Plan Details
Medicare Plan Name:UnitedHealthcare Dual Complete RP (Regional PPO SNP)
Location:Statewide, Florida 33142     Click to see other locations
Plan ID:R5287 - 003 - 0     Click to see other plans
Member Services:1-877-702-5110 TTY users 711
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the UnitedHealthcare Dual Complete RP (Regional PPO SNP) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 for people who qualify for both Medicare and Medicaid. (see Plan Premium Details below)
Annual Deductible:$0 for people who qualify for both Medicare and Medicaid.
Annual Initial Coverage Limit (ICL):$2,970
Health Plan Type:Regional PPO
Special Needs Plan (SNP)
Eligibility Requirement:		Dual-Eligible
Additional Gap Coverage?n/a
Total Number of Formulary Drugs:3,825 drugsBrowse the UnitedHealthcare Dual Complete RP (Regional PPO SNP) Formulary
This plan has 5 drug tiers. See cost-sharing highlights below.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		25%25%25%25%25%
• Number of Drugs per
  Tier:		6612181243796532
Plan's Pharmacy Search:http://www.UHCMedicareSolutions.com
Plan Offers Mail Order?
Number of Members enrolled in this plan in (R5287 - 003):15,936 members
Plan’s Summary Star Rating: 3 out of 5 Stars.
• Customer Service Rating: 4 out of 5 Stars.
• Member Experience Rating: 3 out of 5 Stars.
• Drug Cost Accuracy Rating: 3 out of 5 Stars.
— Plan Premium Details —
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$0.00$0.00$0.00$0.00
— Plan Health Benefits —
** Cost **
Premium and Other Important Information
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services
** Please consult with your plan about cost sharing when receiving services from out-of-network providers.
$24.8 monthly plan premium in addition to your monthly Medicare Part B premium.*
Some physicians providers and suppliers that are out of a plan’s network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare "assignment " your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare "limiting charge." If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare "limiting charge" does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to "assignment" and "limiting charges" that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.go
$6 700 out-of-pocket limit for Medicare-covered services.*
$10 000 out-of-pocket limit for Medicare-covered services.*
** Doctor and Hospital Choice **
Doctor and Hospital Choice
No referral required for network doctors specialists and hospitals.
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits.
** Extra Benefits **
Over-the-Counter Items
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.
Transportation
$0 copay for up to 24 one-way trip(s) to plan approved location every year
75% of the cost for transportation.
** Important Information **
Premium and Other Important Information
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services
** Please consult with your plan about cost sharing when receiving services from out-of-network providers.
$24.8 monthly plan premium in addition to your monthly Medicare Part B premium.*
Some physicians providers and suppliers that are out of a plan’s network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare "assignment " your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare "limiting charge." If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare "limiting charge" does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to "assignment" and "limiting charges" that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.go
$6 700 out-of-pocket limit for Medicare-covered services.*
$10 000 out-of-pocket limit for Medicare-covered services.*
Doctor and Hospital Choice
No referral required for network doctors specialists and hospitals.
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits.
** Inpatient Care **
Inpatient Hospital Care
No limit to the number of days covered by the plan each hospital stay.
$0 or $1 188 copay for each Medicare-covered hospital stay*
$0 copay for each additional hospital day.
30% of the cost for each hospital stay.**
Inpatient Mental Health Care
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.
$0 or $1 188 copay for each Medicare-covered hospital stay*
30% of the cost for each hospital stay.**
Skilled Nursing Facility (SNF)
Plan covers up to 100 days each benefit period
No prior hospital stay is required.
You will not be charged additional cost sharing for professional services
30% of the cost for each SNF stay.**
Home Health Care
$0 copay for each Medicare-covered home health visit*
30% of the cost for Medicare-covered home health visits**
Hospice
You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice.
** Outpatient Care **
Doctor Office Visits
$0 copay for each Medicare-covered primary care doctor visit.*
0% or 20% of the cost for each Medicare-covered specialist visit.*
30% of the cost for each Medicare-covered primary care doctor visit**
30% of the cost for each Medicare-covered specialist visit**
Chiropractic Services
0% or 20% of the cost for each Medicare-covered chiropractic visit*
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor.
30% of the cost for Medicare-covered chiropractic visits.**
Podiatry Services
0% or 20% of the cost for each Medicare-covered podiatry visit*
$0 copay for up to 4 supplemental routine podiatry visit(s) every year
Medicare-covered podiatry visits are for medically-necessary foot care.
30% of the cost for Medicare-covered podiatry visits**
30% of the cost for supplemental routine podiatry visits**
Outpatient Mental Health Care
0% or 20% of the cost for each Medicare-covered individual therapy visit*
0% or 20% of the cost for each Medicare-covered group therapy visit*
0% or 20% of the cost for each Medicare-covered individual therapy visit with a psychiatrist*
0% or 20% of the cost for each Medicare-covered group therapy visit with a psychiatrist*
0% or 20% of the cost for Medicare-covered partial hospitalization program services*
30% of the cost for Medicare-covered Mental Health visits with a psychiatrist**
30% of the cost for Medicare-covered Mental Health visits**
30% of the cost for Medicare-covered partial hospitalization program services**
Outpatient Substance Abuse Care
0% or 20% of the cost for Medicare-covered individual substance abuse outpatient treatment visits*
0% or 20% of the cost for Medicare-covered group substance abuse outpatient treatment visits*
30% of the cost Medicare-covered substance abuse outpatient treatment visits**
Outpatient Services
0% or 20% of the cost for each Medicare-covered ambulatory surgical center visit*
0% or 20% of the cost for each Medicare-covered outpatient hospital facility visit*
30% of the cost for Medicare-covered outpatient hospital facility visits**
30% of the cost for Medicare-covered ambulatory surgical center visits**
Ambulance Services
0% or 20% of the cost for Medicare-covered ambulance benefits.*
30% of the cost for Medicare-covered ambulance benefits.**
Emergency Care
$0 or $65 copay for Medicare-covered emergency room visits*
Worldwide coverage.
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit.
Urgently Needed Care
0% or 20% of the cost for Medicare-covered urgently-needed-care visits*
Outpatient Rehabilitation Services
0% or 20% of the cost for Medicare-covered Occupational Therapy visits*
0% or 20% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits*
30% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits**
30% of the cost for Medicare-covered Occupational Therapy visits.**
** Outpatient Medical Services and Supplies **
Durable Medical Equipment
0% or 20% of the cost for Medicare-covered durable medical equipment*
30% of the cost for Medicare-covered durable medical equipment**
Prosthetic Devices
0% or 20% of the cost for Medicare-covered prosthetic devices*
30% of the cost for Medicare-covered prosthetic devices.**
Diabetes Programs and Supplies
$0 copay for Medicare-covered Diabetes self-management training*
$0 copay for Medicare-covered Diabetes monitoring supplies*
0% or 20% of the cost for Medicare-covered Therapeutic shoes or inserts*
30% of the cost for Medicare-covered Diabetes self-management training**
30% of the cost for Medicare-covered Diabetes monitoring supplies**
30% of the cost for Medicare-covered Therapeutic shoes or inserts**
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
$0 copay for Medicare-covered lab services*
0% or 20% of the cost for Medicare-covered diagnostic procedures and tests*
0% or 20% of the cost for Medicare-covered X-rays*
0% or 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)*
0% or 20% of the cost for Medicare-covered therapeutic radiology services*
30% of the cost for Medicare-covered therapeutic radiology services**
30% of the cost for Medicare-covered outpatient X-rays**
30% of the cost for Medicare-covered diagnostic radiology services**
0% to 30% of the cost for Medicare-covered diagnostic procedures tests and lab services**
** Preventive Services **
Cardiac and Pulmonary Rehabilitation Services
0% or 20% of the cost for Medicare-covered Cardiac Rehabilitation Services*
0% or 20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services*
0% or 20% of the cost for Medicare-covered Pulmonary Rehabilitation Services*
30% of the cost for Medicare-covered Cardiac Rehabilitation Services**
30% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services**
30% of the cost for Medicare-covered Pulmonary Rehabilitation Services**
Preventive Services and Wellness/Education Programs
$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.
This plan does not cover supplemental education/wellness programs.
0% to 30% of the cost for Medicare-covered preventive services**
Kidney Disease and Conditions
0% or 20% of the cost for Medicare-covered renal dialysis*
$0 copay for Medicare-covered kidney disease education services*
30% of the cost for Medicare-covered kidney disease education services**
20% of the cost for Medicare-covered renal dialysis**
Outpatient Prescription Drugs
$0 yearly deductible for Medicare Part B drugs.*
0% or 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.*
30% of the cost for Medicare Part B drugs out-of-network.**
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.UHCMedicareSolutions.com on the web.
Different out-of-pocket costs may apply for people who
  • have limited incomes
  • live in long term care facilities or
  • have access to Indian/Tribal/Urban (Indian Health Service) providers.
The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan’s service area (for instance when you travel).
Total yearly drug costs are the total drug costs paid by you the plan and Medicare.
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.
Your provider must get prior authorization from UnitedHealthcare Dual Complete RP (Regional PPO SNP) for certain drugs.
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan’s website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount.
You pay a $0 annual deductible.
Depending on your income and institutional status you pay the following: For generic drugs (including brand drugs treated as generic) either:
  • A $0 copay or
  • A $1.15 copay or
  • A $2.65 copay
For all other drugs either:
  • A $0 copay or
  • A $3.50 copay or
  • A $6.60 copay.
You can get drugs the following way(s):
  • one-month (31-day) supply
  • three-month (90-day) supply
    • You can get drugs the following way(s):
    • one-month (31-day) supply of generic drugs
  • 31-day supply of brand drugs.
    • Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed.
    You can get drugs the following way(s):
    • three-month (90-day) supply
    After your yearly out-of-pocket drug costs reach $4 750 you pay a $0 copay.
    Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy’s full charge for the drug and submit documentation to receive reimbursement from UnitedHealthcare Dual Complete RP (Regional PPO SNP).
    You can get out-of-network drugs the following way:
    • one-month (31-day) supply
    Depending on your income and institutional status you will be reimbursed by UnitedHealthcare Dual Complete RP (Regional PPO SNP) up to the plan’s cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic) either:
  • A $0 copay or
  • A $1.15 copay or
  • A $2.65 copay
    • For all other drugs purchased out-of-network either:
    • A $0 copay or
    • A $3.50 copay or
    • A $6.60 copay.
    After your yearly out-of-pocket drug costs reach $4 750 you will be reimbursed in full for drugs purchased out-of-network.
    Dental Services
    0% or 20% of the cost for Medicare-covered dental benefits*
    • $0 copay for up to 1 oral exam(s) every six months
  • $0 copay for up to 1 cleaning(s) every six months
  • $0 copay for up to 1 dental x-ray(s)
    • 30% of the cost for Medicare-covered comprehensive dental benefits**
    $40 copay for supplemental preventive dental benefits
    Hearing Services
    In general supplemental routine hearing exams and hearing aids not covered.
    0% or 20% of the cost for Medicare-covered diagnostic hearing exams*
    30% of the cost for Medicare-covered diagnostic hearing exams.**
    ** Additional Benefits **
    Vision Services
    • $0 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery*
  • 0% or 20% of the cost for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.*
  • $0 copay for up to 1 supplemental routine eye exam(s) every two years
  • $0 copay for contacts
  • $0 copay for up to 1 pair(s) of lenses every two years
  • $0 copay for up to 1 frame(s) every two years
    • 30% of the cost for Medicare-covered eye exams**
    30% of the cost for supplemental eye exams**
    $0 copay for Medicare-covered eye wear**
    $0 copay for supplemental eye wear**
    $100 plan coverage limit for eye wear every two years. This limit applies to both in-network and out-of-network benefits.
    Over-the-Counter Items
    Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.
    Transportation
    $0 copay for up to 24 one-way trip(s) to plan approved location every year
    75% of the cost for transportation.
    Acupuncture
    This plan does not cover Acupuncture.
    ** Inpatient Care **
    Inpatient Hospital Care
    No limit to the number of days covered by the plan each hospital stay.
    $0 or $1 188 copay for each Medicare-covered hospital stay*
    $0 copay for each additional hospital day.
    30% of the cost for each hospital stay.**
    ** Outpatient Care **
    Doctor Office Visits
    $0 copay for each Medicare-covered primary care doctor visit.*
    0% or 20% of the cost for each Medicare-covered specialist visit.*
    30% of the cost for each Medicare-covered primary care doctor visit**
    30% of the cost for each Medicare-covered specialist visit**
    Outpatient Services
    0% or 20% of the cost for each Medicare-covered ambulatory surgical center visit*
    0% or 20% of the cost for each Medicare-covered outpatient hospital facility visit*
    30% of the cost for Medicare-covered outpatient hospital facility visits**
    30% of the cost for Medicare-covered ambulatory surgical center visits**
    Ambulance Services
    0% or 20% of the cost for Medicare-covered ambulance benefits.*
    30% of the cost for Medicare-covered ambulance benefits.**
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    0% or 20% of the cost for Medicare-covered durable medical equipment*
    30% of the cost for Medicare-covered durable medical equipment**
    Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    $0 copay for Medicare-covered lab services*
    0% or 20% of the cost for Medicare-covered diagnostic procedures and tests*
    0% or 20% of the cost for Medicare-covered X-rays*
    0% or 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)*
    0% or 20% of the cost for Medicare-covered therapeutic radiology services*
    30% of the cost for Medicare-covered therapeutic radiology services**
    30% of the cost for Medicare-covered outpatient X-rays**
    30% of the cost for Medicare-covered diagnostic radiology services**
    0% to 30% of the cost for Medicare-covered diagnostic procedures tests and lab services**
    ** Additional Benefits **
    Over-the-Counter Items
    Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.
    Transportation
    $0 copay for up to 24 one-way trip(s) to plan approved location every year
    75% of the cost for transportation.




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