** 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 |
$36.4 monthly plan premium in addition to your monthly Medicare Part B premium.* |
$6 700 out-of-pocket limit for Medicare-covered services.* |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
No referral required for network doctors specialists and hospitals. |
** 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 |
This plan does not cover supplemental routine 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 |
$36.4 monthly plan premium in addition to your monthly Medicare Part B premium.* |
$6 700 out-of-pocket limit for Medicare-covered services.* |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
No referral required for network doctors specialists and hospitals. |
** 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. |
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* |
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 |
Home Health Care |
$0 copay for each Medicare-covered home health visit* |
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% or 20% of the cost for each Medicare-covered primary care doctor visit.* |
0% or 20% 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. |
Podiatry Services |
0% or 20% of the cost for each Medicare-covered podiatry visit* |
$0 copay for up to 2 supplemental routine podiatry visit(s) every year |
Medicare-covered podiatry visits are for medically-necessary foot care. |
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* |
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* |
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* |
Ambulance Services |
0% or 20% 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* |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
0% or 20% of the cost for Medicare-covered durable medical equipment* |
Prosthetic Devices |
0% or 20% 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* |
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* |
** 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* |
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. |
The plan covers the following supplemental education/wellness programs: |
|
Kidney Disease and Conditions |
0% or 20% of the cost for Medicare-covered renal dialysis* |
$0 copay for Medicare-covered kidney disease education services* |
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.* |
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 LP (HMO 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 LP (HMO 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 LP (HMO 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) |
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* |
** Additional Benefits ** |
Vision Services |
This plan offers only Medicare-covered eye care and eye wear |
- $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.* |
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 |
This plan does not cover supplemental routine 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. |
** Outpatient Care ** |
Doctor Office Visits |
0% or 20% of the cost for each Medicare-covered primary care doctor visit.* |
0% or 20% 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* |
Ambulance Services |
0% or 20% 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* |
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* |
** 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 |
This plan does not cover supplemental routine transportation. |