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October 15

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Your plan details for Plans for
06404 Fairfield County

UHC Dual Complete CT-Q001 (PPO D-SNP)

Extra Help is applied

Learn More about Extra Help

Look for the green-colored pricing as you shop for plans to see your potential cost savings shown by the crossed out dollar amount.

The information provided in this document may be subject to change over time and may become outdated. For the most current and up-to-date information, please refer to our website at UHC.com/medicare.

  • Monthly premium

    new former $0

  • $0
    when using an in-network provider
    $0

    when using an in and out-of-network provider

  • $0 copay for Tier 1 prescriptions
  • $0 PCP and $0 specialist visits
  • $0 copay for network dental like exams, x-rays, routine cleanings and fluoride
  • $47 credit every month for OTC, plus healthy for qualifying members
  • $150 allowance for eyewear every year, plus $0 copay for a routine eye exam and lenses
  • $1,500 allowance for a broad selection of OTC and brand-name hearing aids
  • No transportation coverage

Explore the plan details

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Explore the plan details

Eligibility

Special eligibility requirement

Must be a Qualified Medicare Beneficiary (QMB) who doesn't have full Medicaid benefits but gets all their Medicare-covered services provided at $0. CT: QMB

Doctor visits

$0

when using an in and out-of-network provider

Covered for urgent and emergency care only

$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider

Specialist

$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider

Virtual visits

$0 copay

to talk with a network telehealth provider online through live audio and video.

Annual routine physical

1 per year
$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider

Preventive services (such as covered screenings, vaccinations, etc.)

$0 copay

for covered services

when using an in-network provider
$0 copay

for covered services

when using an out-of-network provider

Group therapy visit

$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider

Individual therapy visit

$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider

Opioid treatment services

$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider

Medical benefit information

Inpatient hospital care

$0

per stay for unlimited days

when using an in-network provider
$0

per stay for unlimited days

when using an out-of-network provider

Skilled nursing facility

$0 copay

per day: days 1-100

when using an in-network provider
$0 copay

per day: days 1-100

when using an out-of-network provider

Outpatient hospital services (including surgery and observation)

$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider

Ambulatory surgical center

$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider

Physical and speech therapy

$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider

Occupational therapy

$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider

Lab services

$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider

Outpatient X-rays

$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider

Diagnostic tests and procedures, non-radiological (such as EKG/ECG tests, etc.)

$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider

Diagnostic radiology services (such as MRIs, CT scans, etc.)

$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider

Diabetes monitoring supplies

$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider
Covered items include: Continuous glucose monitors (CGMs), blood glucose monitors, blood glucose test strips, lancet devices, lancets and glucose-control solutions for checking the accuracy of test strips and monitors (select brands only). Insulin and syringes are covered under your Part D prescription drug benefit.

Home health care

$0 copay
when using an in-network provider
$0 copay
when using an out-of-network provider

Urgent care

$0 copay

per visit ($0 copay when outside of the United States)

Emergency care

$0 copay

per visit ($0 copay when outside of the United States)

Ambulance services

$0 copay

for ground or air

Prescription drug benefits

Annual prescription deductible

$0

if you qualify for Extra Help

$0

for Tier 1

$615

for Tiers 2-5 if you do not qualify for Extra Help

Retail network pharmacy (30-day supply)

Tier 1: Preferred Generic Drugs

$0 copay

Standard network

Tier 2: Generic Drugs

25% of the cost

Standard network

Tier 3: Preferred Brand Drugs

25% of the cost

Standard network

Tier 3: Insulin

Up to $35 copay

Standard network

Tier 4: Non-Preferred Drugs

25% of the cost

Standard network

Tier 5: Specialty Drugs

25% of the cost

Standard network


Mail order pharmacy

Tier 1: Preferred Generic Drugs

$0 copay

Tier 2: Generic Drugs

25% of the cost

Tier 3: Preferred Brand Drugs

25% of the cost

Tier 3: Insulin

Up to $105 copay

Cost shares if you receive Extra Help

Extra Help is a Medicare program with benefits like: lower monthly plan premium, lower prescription copays, $0 drug deductibles. Learn more

Brand Drugs

Up to $12.65 copay

Generic Drugs

Up to $5.10 copay

Cost shares if you receive Extra Help

Extra Help is a Medicare program with benefits like: lower monthly plan premium, lower prescription copays, $0 drug deductibles. Learn more

Brand Drugs

$12.65

Generic Drugs

$5.10

Cost shares if you receive Extra Help

Extra Help is a Medicare program with benefits like: lower monthly plan premium, lower prescription copays, $0 drug deductibles. Learn more

Brand Drugs

$4.90

Generic Drugs

$1.60

Cost shares if you receive Extra Help

Extra Help is a Medicare program with benefits like: lower monthly plan premium, lower prescription copays, $0 drug deductibles. Learn more

Brand Drugs

$0

Generic Drugs

$0

Dental coverage

Routine dental

$0 copay

for covered preventive services such as oral exams, routine cleanings, X-rays and fluoride


You will have access to one of Medicare Advantage's largest dental networks, or you can choose any dentist.

See the UnitedHealthcare plan difference

Access to one of Medicare Advantage’s largest national networks of vision providers and retail providers. Eyewear available from many online providers, including Warby Parker and GlassesUSA.

Home-delivered eyewear available nationwide only through UnitedHealthcare Vision (select products only).

Routine eye exam

1 exam per year
$0 copay
when using an in-network provider
30% of the cost
when using an out-of-network provider

Routine eyewear

$0 copay

for standard prescription lenses

$150 allowance

every year for 1 pair of lenses/frames or contacts.

Hearing sounds better with more access

Choose from a broad selection of OTC and brand-name prescription hearing aids through UnitedHealthcare Hearing.

Access to one of the largest national networks with thousands of hearing professionals.

Routine hearing exam

1 exam per year
$0 copay
when using an in-network provider
30% of the cost
when using an out-of-network provider

Hearing aids

$1,500 allowance

up to 2 hearing aids every 2 years

Get more for your everyday needs

OTC, healthy food, utilities + wellness support

$47 credit

per month for OTC products and wellness support, plus healthy food and utilities for members with a qualifying condition such as diabetes, cardiovascular disorders, chronic heart failure, chronic high blood pressure and/or chronic high cholesterol. Buy first aid supplies, pain relievers, fruits, meat and more or pay home utilities like electricity or internet. Get wellness support including in-home services, select fitness items and more.

OTC, healthy food, utilities + wellness support

$47 credit

per month for OTC products and wellness support, plus healthy food and utilities for members with a qualifying condition such as diabetes, cardiovascular disorders, chronic heart failure, chronic high blood pressure and/or chronic high cholesterol. Buy first aid supplies, pain relievers, fruits, meat and more or pay home utilities like electricity or internet. Get wellness support including in-home services, select fitness items and more.

Rewards

Earn up to $180

in rewards every year for getting an annual wellness visit, being physically active, connecting with others and more.

Rewards

Earn up to $180

in rewards every year for getting an annual wellness visit, being physically active, connecting with others and more.

Routine foot care

4 visits per year
$0 copay
when using an in-network provider
30% of the cost
when using an out-of-network provider

Meal benefit

$0 copay

for 28 home-delivered meals immediately after an inpatient hospitalization or skilled nursing facility (SNF) stay.

Plan resources

Important documents that provide the details you need about this plan's coverage and benefits, prescription drugs, enrollment, providers and more.

Language

Medical Providers

Online Medical and Behavioral Health Directory Opens in a new window

General Plan Information

Prescription Drug Coverage

Pharmacy Directory

Online Pharmacy Directory Opens in a new tab

Medical Providers

General Plan Information

Prescription Drug Coverage

Pharmacy Directory

Directorio de Farmacias en Internet Opens in a new tab
網站查詢網上藥房名冊 Opens in a new tab
footnote
Disclaimer information

 

Enrollment Disclaimer Information:

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in these plans depends on the plan’s contract renewal with Medicare. Enrollment in a Dual Special Needs plan (D-SNP) depends on the plan's contract renewal with a Medicare Advantage organization with a Medicare contract and a contract with the state Medicaid program.

 

AARP-related Disclaimer:

UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers. You do not need to be an AARP member to enroll in a Medicare Advantage or Prescription Drug Plan. AARP encourages you to consider your needs when selecting products and does not make specific product recommendations for individuals. AARP does not employ or endorse agents, producers or brokers.

 

Extra Help: 

If you are receiving Extra Help from Medicare, your copays may be lower or you may have no copays. 

 

Out-of-network:

Out-of-network/non-contracted providers are under no obligation to treat members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. 

 

The Medicare Prescription Payment Plan: 

If you have high out-of-pocket costs for your covered Part D prescription drugs each year, you may want to participate in the Medicare Prescription Payment Plan. This payment plan spreads your out-of-pocket prescription drug costs over the remainder of the calendar year. Learn more about the Medicare Prescription Payment Plan.<

 

State-level Medicaid, D-SNP Disclaimer:

D-SNP and C-SNP: The values shown in-network represent a range based upon the amount of the Medicare Parts A and B plan cost sharing covered by the state. Depending on your Medicaid eligibility, your Medicaid program may have cost sharing. Additionally, plan-specific contract information may also vary. For complete information, and for costs for those without Medicare Parts A and B plan cost sharing covered by the state, and applicable Medicaid cost sharing, please refer to your Summary of Benefits or Evidence of Coverage. Limitations, exclusions, and restrictions may apply.

Some of the benefits on a Dual Special Needs plan may also be available from the state Medicaid program or a managed Medicaid plan..

For state-level specific disclaimers, click here.

 

Other Languages:

This information is available for free in other languages. Please contact Customer Service for additional information. 

 

Esta información está disponible sin costo en otros idiomas. Para obtener más información comuníquese con nuestro Servicio al Cliente. 

 

本資訊可以其他語言免費提供。如需更多資訊,請聯絡客戶服務部。 

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