UHC Dual Complete NE-S002 (PPO D-SNP)
Available to residents of Dodge County, NE for 2026. Contract H2001, plan 054, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Dodge County
- Plan website
- Browse the UHC Dual Complete NE-S002 (PPO D-SNP) formulary
Renewed, service area reduced for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $41.50 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $41.50? |
| Drug premium in CMS's quarterly plan file | $0.00The CMS Landscape file above lists $41.50 for the drug part; the two CMS files differ for this plan. |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | $0.70 a month?You must continue to pay your Medicare Part B premium. |
| In-network out-of-pocket maximum | $9,250.00? |
| In- and out-of-network out-of-pocket maximum | $13,900.00 |
| Drug deductible | $615.00Tier 1 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | PPO D-SNP? |
| Special needs plan | Dual-eligible SNP |
| Contract / plan | H2001-054-0 |
| Offered by | UnitedHealthcare |
| Parent organization | UnitedHealth Group, Inc. |
| Formulary drugs | 3,609 |
| Formulary exception tier | 4? |
| Pharmacy search | UHC.com/CommunityPlan |
| Member services | (888)834-3721TTY 711 |
CMS star ratings
- Overall
- 4.5 out of 5 stars for Overall
- Health plan (Part C)
- 4.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 4 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H2001 shares this rating.
Plan health benefits
| Service | In-network | Out-of-network? |
|---|---|---|
| Doctor visits | ||
| Primary care doctor | 0%–20% coinsurance | 30% coinsurance |
| Specialist | 0%–20% coinsurance(authorization required) | 30% coinsurance |
| Other health care professional | 0%–20% coinsurance(authorization required) | 30% coinsurance |
| Additional telehealth services | $0 copay | — |
| Preventive care | ||
| Medicare-covered preventive services | $0 copay | 0%–40% coinsurance |
| Annual physical exam | $0 copay | 40% coinsurance |
| Kidney disease education | $0 copay | 40% coinsurance |
| Glaucoma screening | $0 copay | 40% coinsurance |
| Diabetes self-management training | $0 copay | 40% coinsurance |
| Diagnostic tests, labs and imaging | ||
| Diagnostic tests and procedures | 20% coinsurance(authorization required) | 40% coinsurance |
| Lab services | $0 copay(authorization required) | $0 copay |
| Diagnostic radiology (e.g. MRI, CT) | 0%–20% coinsurance(authorization required) | 40% coinsurance |
| Therapeutic radiology | 20% coinsurance(authorization required) | 20% coinsurance |
| Outpatient x-rays | 20% coinsurance(authorization required) | 40% coinsurance |
| Emergency and urgent care | ||
| Emergency room | $115 copay | — |
| Urgent care | $0–$40 copay | — |
| Worldwide emergency coverage | $0 copay | — |
| Worldwide urgent care | $0 copay | — |
| Worldwide emergency transportation | $0 copay | — |
| Hospital care | ||
| Inpatient hospital stay | $2,230 per stay; $0 per day for days 91–999 (additional days)(authorization required) | $2,230 per stay |
| Outpatient hospital services | 0%–20% coinsurance(authorization required) | 40% coinsurance |
| Outpatient observation | 20% coinsurance(authorization required) | 40% coinsurance |
| Ambulatory surgical center | 0%–20% coinsurance(authorization required) | 40% coinsurance |
| Outpatient blood services | 20% coinsurance(authorization required) | 40% coinsurance |
| Skilled nursing and home health | ||
| Skilled nursing facility | Original Medicare cost-sharing(authorization required) | Original Medicare cost-sharing |
| Home health care | $0 copay(authorization required) | $0 copay |
| Kidney dialysis | 20% coinsurance(authorization required) | 20% coinsurance |
| Rehabilitation | ||
| Occupational therapy | 20% coinsurance(authorization required) | 30% coinsurance |
| Physical therapy and speech-language therapy | 20% coinsurance(authorization required) | 30% coinsurance |
| Cardiac rehabilitation | 20% coinsurance(authorization required) | 30% coinsurance |
| Pulmonary rehabilitation | 20% coinsurance(authorization required) | 30% coinsurance |
| Mental health and substance use | ||
| Inpatient psychiatric hospital stay | $2,080 per stay(authorization required) | $2,080 per stay |
| Outpatient mental health, individual session | 0%–20% coinsurance(authorization required) | 30% coinsurance |
| Outpatient mental health, group session | 20% coinsurance(authorization required) | 30% coinsurance |
| Psychiatrist, individual session | 0%–20% coinsurance(authorization required) | 30% coinsurance |
| Psychiatrist, group session | 20% coinsurance(authorization required) | 30% coinsurance |
| Partial hospitalization | $55 copay(authorization required) | 30% coinsurance |
| Intensive outpatient program | $55 copay(authorization required) | 30% coinsurance |
| Outpatient substance use, individual session | 0%–20% coinsurance(authorization required) | 30% coinsurance |
| Outpatient substance use, group session | 20% coinsurance(authorization required) | 30% coinsurance |
| Opioid treatment program | $0 copay(authorization required) | $0 copay |
| Ambulance and transportation | ||
| Ground ambulance | 20% coinsurance(authorization required) | 20% coinsurance |
| Air ambulance | 20% coinsurance(authorization required) | 20% coinsurance |
| Transportation to plan-approved locations | $0 copay(limits apply) | 75% coinsurance |
| Medical equipment and supplies | ||
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) | 20% coinsurance |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) | 20% coinsurance |
| Medical supplies | 20% coinsurance(authorization required) | 20% coinsurance |
| Diabetes supplies | $0 copay(authorization required) | 20% coinsurance |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) | 20% coinsurance |
| Chiropractic, acupuncture and foot care | ||
| Chiropractic (Medicare-covered) | 20% coinsurance(authorization required) | 30% coinsurance |
| Routine chiropractic care | Not covered | — |
| Acupuncture | Not covered | — |
| Foot exams and treatment (Medicare-covered) | 20% coinsurance(authorization required) | 30% coinsurance |
| Routine foot care | $0 copay(authorization required, limits apply) | 30% coinsurance |
| Dental? | ||
| Medicare-covered dental services | 20% coinsurance(authorization required) | 40% coinsurance |
| Preventive dental plan limit | $2,000 plan limit every year | — |
| Oral exams | $0 copay(limits apply) | $0 copay |
| Cleanings | $0 copay(limits apply) | $0 copay |
| Fluoride treatment | $0 copay(limits apply) | $0 copay |
| Dental x-rays | $0 copay(limits apply) | $0 copay |
| Other diagnostic dental services | $0 copay(limits apply) | $0 copay |
| Other preventive dental services | $0 copay(limits apply) | $0 copay |
| Restorative services (fillings, crowns) | $0 copay(authorization required, limits apply) | $0 copay |
| Endodontics (root canals) | $0 copay(authorization required, limits apply) | $0 copay |
| Periodontics (gum disease) | $0 copay(authorization required, limits apply) | $0 copay |
| Dentures and other removable prosthodontics | $0 copay(authorization required, limits apply) | $0 copay |
| Maxillofacial prosthetics | $0 copay(authorization required, limits apply) | $0 copay |
| Implants | Not covered | — |
| Bridges and other fixed prosthodontics | $0 copay(authorization required, limits apply) | $0 copay |
| Oral and maxillofacial surgery | $0 copay(authorization required, limits apply) | $0 copay |
| Orthodontics | Not covered | — |
| Adjunctive general services | $0 copay(authorization required, limits apply) | $0 copay |
| Vision? | ||
| Eye exam (Medicare-covered) | $0 copay(authorization required) | 30% coinsurance |
| Routine eye exam | $0 copay(authorization required, limits apply) | 30% coinsurance |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) | 40% coinsurance |
| Eyewear plan limit | $200 plan limit every year | — |
| Contact lenses | $0 copay(limits apply) | $0 copay |
| Eyeglasses (frames and lenses) | Not covered | — |
| Eyeglass lenses | $0 copay(limits apply) | $0 copay |
| Eyeglass frames | $0 copay(limits apply) | $0 copay |
| Eyewear upgrades | Not covered | — |
| Hearing? | ||
| Hearing exam (Medicare-covered) | 20% coinsurance(authorization required) | 30% coinsurance |
| Routine hearing exam | $0 copay(authorization required, limits apply) | 30% coinsurance |
| Hearing aid fitting and evaluation | Not covered | — |
| Hearing aid plan limit | $1,500 plan limit every two years | — |
| Hearing aids (all types) | $0 copay(authorization required, limits apply) | $0 copay |
| Hearing aids, inner ear | Not covered | — |
| Hearing aids, outer ear | Not covered | — |
| Hearing aids, over the ear | Not covered | — |
| Medicare Part B drugs | ||
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) | 20% coinsurance |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 20% coinsurance |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 20% coinsurance |
| Other extra benefits? | ||
| Over-the-counter (OTC) allowance | Covered (allowance not stated) | — |
| Meals after a hospital stay or for a chronic condition | $0 copay(authorization required) | $0 copay |
| Fitness benefit | $0 copay | $0 copay |
| Health education | Not covered | — |
| Nutritional / dietary benefit | Not covered | — |
| Extra smoking and tobacco cessation counseling | Not covered | — |
| Enhanced disease management | Not covered | — |
| Telemonitoring | Not covered | — |
| Remote access technologies (web/phone, nurse line) | Not covered | — |
| Home and bathroom safety devices | $0 copay | $0 copay |
| Counseling services | Not covered | — |
| In-home safety assessment | Not covered | — |
| Personal emergency response system (PERS) | Not covered | — |
| Medical nutrition therapy | Not covered | — |
| Post-discharge in-home medication reconciliation | Not covered | — |
| Re-admission prevention | Not covered | — |
| Wigs for hair loss from chemotherapy | Not covered | — |
| Weight management programs | $0 copay | 75% coinsurance |
| Alternative therapies | Not covered | — |
| Therapeutic massage | Not covered | — |
| Adult day health services | Not covered | — |
| Home-based palliative care | Not covered | — |
| In-home support services | $0 copay | 75% coinsurance |
| Support for caregivers | $0 copay | 75% coinsurance |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | 25% |
| Tier 3 | 25% |
| Tier 4 | 25% |
| Tier 5 | 25% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | 25% | 25% | n/a | 25% | 25% | 25% |
| Tier 3: Preferred Brand | 25% | 25% | n/a | 25% | 25% | 25% |
| Tier 4: Non-Preferred Drug | 25% | 25% | 25% | n/a | n/a | n/a |
| Tier 5: Specialty Tier | 25% | 25% | 25% | n/a | n/a | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 76 other NE counties
- Adams
- Antelope
- Banner
- Blaine
- Boone
- Boyd
- Buffalo
- Burt
- Butler
- Cass
- Cedar
- Cherry
- Cheyenne
- Clay
- Colfax
- Cuming
- Custer
- Dakota
- Dawes
- Dawson
- Deuel
- Dixon
- Douglas
- Fillmore
- Franklin
- Frontier
- Furnas
- Gage
- Garfield
- Gosper
- Greeley
- Hall
- Hamilton
- Harlan
- Holt
- Howard
- Jefferson
- Johnson
- Kearney
- Keith
- Keya Paha
- Kimball
- Knox
- Lancaster
- Logan
- Loup
- Madison
- Merrick
- Morrill
- Nance
- Nemaha
- Nuckolls
- Otoe
- Pawnee
- Perkins
- Phelps
- Pierce
- Platte
- Polk
- Richardson
Benefits in plain text
UHC Dual Complete NE-S002 (PPO D-SNP) (H2001-054-0) is a 2026 PPO D-SNP Medicare Advantage plan offered by UnitedHealthcare, available to residents of Dodge County, NE.
The monthly premium is $41.50 (Part C and Part D together).
The plan reduces the member's Medicare Part B premium by $0.70 a month (a "giveback"); the Part B premium itself must still be paid.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
Its in-network out-of-pocket maximum is $9,250.00.
The combined in- and out-of-network out-of-pocket maximum is $13,900.00.
The drug deductible is $615.00. Tier 1 exempt.
It is a special needs plan (Dual-eligible SNP).
The plan's formulary lists 3,609 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: 25%; tier 3: 25%; tier 4: 25%; tier 5: 25%.
CMS gives the plan's contract (H2001) an overall rating of 4.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.