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See how much you'll pay for this plan including your premium, deductible and maximum out-of-pocket costs.
| Costs | In-network - What you'll pay | Out-of-network - What you'll pay |
|---|---|---|
| Monthly Premium Monthly Premium 1 $35.30$35.30 | $35.30 | |
Annual Medical Deductible
Annual Medical Deductible
Annual Medical Deductible
The pre-set, fixed amount you must pay for health care costs before the insurance company or Medicare begins to pay. Please see your Evidence of Coverage for details.
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No deductible | |
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Out-of-Pocket Maximum
Out-of-Pocket Maximum
Out-of-Pocket Maximum
This is the highest amount of money you have to pay out of your pocket for cost sharing (copayments and coinsurance) charged for certain covered services during a calendar year. Not all copayments or coinsurance amounts you pay apply toward the annual out-of-pocket maximum. See the plan’s Evidence of Coverage for more information.
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$1,800 | $5,100 combined in- and-out-of-network |
Find out if your doctors are in-network for this plan, as well as copays and referral requirements.
| Costs | In-network - what you'll pay | Out-of-network - what you'll pay |
|---|---|---|
| Primary Care Provider Primary Care Provider $0 copay30% of the cost | $0 copay | 30% of the cost |
| Specialist Specialist 0% of the cost - 20% of the cost30% of the cost | 0% of the cost - 20% of the cost | 30% of the cost |
| Referral Required Referral Required NoNo | No | No |
Learn about this plan's prescription drug coverage and costs. Enter your prescriptions to see what they'd cost with this plan.
| Costs | What you'll pay |
|---|---|
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Annual Prescription Deductible
Annual Prescription Deductible
If your plan has an annual deductible, you (or others on your behalf) will pay your drug costs up to the amount of this deductible before moving into the Initial Coverage Stage.
If you qualify for Extra Help in 2023, then your annual prescription deductible will be $0 or $104 depending on the level of Extra Help you receive. |
$505 If you qualify for Extra Help in 2023, then your annual prescription deductible will be $0 or $104 depending on the level of Extra Help you receive. |
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Covered Insulin Drugs
Covered Insulin Drugs
For Chronic Special Needs Plans: You will pay a maximum of $25 for each 1-month supply of Part D select insulin drug through all coverage stages. For All Other Plans: You will pay a maximum of $35 for each 1-month supply of Part D covered insulin drug through all coverage stages. Cost Sharing (30 days) $35 copay Standard Mail Order Pharmacy (100 days) $105 copay |
Standard Network Pharmacy Cost Sharing (30 days) $35 copay Standard Mail Order Pharmacy (100 days) $105 copay |
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Initial Coverage Stage - No LIS
Standard Network Pharmacy Cost Sharing (30 days) 25% coinsurance Standard Mail Order Pharmacy (100 days) 25% coinsurance |
Standard Network Pharmacy Cost Sharing (30 days) 25% coinsurance Standard Mail Order Pharmacy (100 days) 25% coinsurance |
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Initial Coverage Stage - If you qualify for LIS (Extra Help)
Generic (including brand drugs treated as generic) $0, $1.45, $4.15 copay, or 15% of the total cost All Other Drugs $0, $4.30, $10.35 copay, or 15% of the total cost |
Generic (including brand drugs treated as generic) $0, $1.45, $4.15 copay, or 15% of the total cost All Other Drugs $0, $4.30, $10.35 copay, or 15% of the total cost |
| Coverage Gap Stage 7 During the Coverage Gap Stage, you (or others on your behalf) will pay no more than 25% of the price for generic drugs or 25% of the price (plus the dispensing fee) for brand name drugs, for any drug tier until the total amount you (or others on your behalf) have paid reaches $7,400 in year-to-date out-of-pocket costs. You may pay less if your plan has additional coverage in the gap. | During the Coverage Gap Stage, you (or others on your behalf) will pay no more than 25% of the price for generic drugs or 25% of the price (plus the dispensing fee) for brand name drugs, for any drug tier until the total amount you (or others on your behalf) have paid reaches $7,400 in year-to-date out-of-pocket costs. You may pay less if your plan has additional coverage in the gap. |
| Catastrophic Coverage Stage After your total out-of-pocket costs reach $7,400, you will pay the greater of $4.15 copay for generic (including brand drugs treated as generic), and $10.35 copay for all other drugs, or 5% coinsurance. | After your total out-of-pocket costs reach $7,400, you will pay the greater of $4.15 copay for generic (including brand drugs treated as generic), and $10.35 copay for all other drugs, or 5% coinsurance. |
Learn about this plan's dental coverage options, costs and networks for your dentist.
| Costs | What you'll pay |
|---|---|
|
Dental
$3,500 per year for covered dental services. $0 copay for covered network preventive services including oral exams, routine cleanings, X-rays and fluoride. $0 copay for covered network comprehensive services such as fillings, crowns, root canals, extractions, dentures and implants. You will have access to Medicare Advantage's largest dental network, or you can choose any dentist that accepts Medicare. Seeing a network dentist may save you money. |
$3,500 per year for covered dental services. $0 copay for covered network preventive services including oral exams, routine cleanings, X-rays and fluoride. $0 copay for covered network comprehensive services such as fillings, crowns, root canals, extractions, dentures and implants. You will have access to Medicare Advantage's largest dental network, or you can choose any dentist that accepts Medicare. Seeing a network dentist may save you money. |
See this plan's benefits, costs and copays. For full plan details, see the Evidence of Coverage or Summary of Benefits under the Plan Documents section.
| Costs | In-network - What you'll pay | Out-of-network - What you'll pay |
|---|---|---|
| Ambulatory Surgical Center Ambulatory Surgical Center 2 $0 copay - 20% of the cost30% of the cost | $0 copay - 20% of the cost | 30% of the cost |
| Diabetes Monitoring Supplies Diabetes Monitoring Supplies 2 20% of the cost30% of the cost | 20% of the cost | 30% of the cost |
| Diagnostic Radiology Services (such as MRIs/CT scans, etc.) Diagnostic Radiology Services (such as MRIs/CT scans, etc.) 0% of the cost - 20% of the cost30% of the cost | 0% of the cost - 20% of the cost | 30% of the cost |
| Diagnostic Tests and Procedures, non-radiological (such as EKG/ECG tests, etc.) Diagnostic Tests and Procedures, non-radiological (such as EKG/ECG tests, etc.) 20% of the cost30% of the cost | 20% of the cost | 30% of the cost |
| Emergency Care Emergency Care $90 copay per visit always covered when you need it$90 copay per visit always covered when you need it | $90 copay per visit always covered when you need it | |
| Ambulance Services Ambulance Services 20% of the cost for ground or air20% of the cost for ground or air | 20% of the cost for ground or air | 20% of the cost for ground or air |
| Home Health Care Home Health Care $0 copay30% of the cost | $0 copay | 30% of the cost |
| Inpatient Hospital Care Inpatient Hospital Care $1,556 per stay$1,556 per stay | $1,556 per stay | $1,556 per stay |
| Lab Services Lab Services $0 copay$0 copay | $0 copay | $0 copay |
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Mental Health (outpatient)
Mental Health (outpatient)
Group: 20% of the cost Individual: 20% of the cost Group: 30% of the cost Individual: 30% of the cost |
Group: 20% of the cost Individual: 20% of the cost |
Group: 30% of the cost Individual: 30% of the cost |
| Opioid Treatment Services Opioid Treatment Services $0 copay$0 copay | $0 copay | $0 copay |
| Outpatient Hospital Services (includes observation services) Outpatient Hospital Services (includes observation services) 2 $0 copay - 20% of the cost30% of the cost | $0 copay - 20% of the cost | 30% of the cost |
| Outpatient X-rays Outpatient X-rays $0 copay30% of the cost | $0 copay | 30% of the cost |
| Preventive Services (such as covered screenings, vaccinations, etc.) Preventive Services (such as covered screenings, vaccinations, etc.) 2 $0 copay for covered services$0 copay - 30% of the cost (depending on the service) | $0 copay for covered services | $0 copay - 30% of the cost (depending on the service) |
| Skilled Nursing Facility Skilled Nursing Facility $0 copay per day: Days 1-10030% of the cost | $0 copay per day: Days 1-100 | 30% of the cost |
| Urgent Care Urgent Care $40 copay per visit always covered when you need it$40 copay per visit always covered when you need it | $40 copay per visit always covered when you need it | |
See more of the benefits and programs offered by this plan that are not provided under Original Medicare. For full plan details, see the Evidence of Coverage or Summary of Benefits under the Plan Documents section.
| Costs | In-network - What you'll pay | Out-of-network - What you'll pay |
|---|---|---|
| Eye Exam Eye Exam 3 $0 copay; 1 per year30% of the cost; combined visits In and Out of Network | $0 copay; 1 per year | 30% of the cost; combined visits In and Out of Network |
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Routine Eyewear
Routine Eyewear
3
$0 copay Plan pays up to $300 every year for frames or contact lenses. Standard single, bifocal, trifocal, or progressive lenses are covered in full. Home delivered eyewear available nationwide only through UnitedHealthcare Vision (select products only).$0 copay Plan pays up to $300 every year for frames or contact lenses. Standard single, bifocal, trifocal, or progressive lenses are covered in full. Home delivered eyewear available nationwide only through UnitedHealthcare Vision (select products only). |
$0 copay Plan pays up to $300 every year for frames or contact lenses. Standard single, bifocal, trifocal, or progressive lenses are covered in full. Home delivered eyewear available nationwide only through UnitedHealthcare Vision (select products only). |
|
| Hearing Exam Hearing Exam 3 $0 copay; 1 per year30% of the cost; combined visits In and Out of Network | $0 copay; 1 per year | 30% of the cost; combined visits In and Out of Network |
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Hearing Aids
Hearing Aids
3
Plan pays up to $2,000 for hearing aids, up to 2 hearing aids every year through UnitedHealthcare Hearing. Includes hearing aids delivered directly to you with virtual follow-up care (select models).Plan pays up to $2,000 for hearing aids, up to 2 hearing aids every year through UnitedHealthcare Hearing. Includes hearing aids delivered directly to you with virtual follow-up care (select models). |
Plan pays up to $2,000 for hearing aids, up to 2 hearing aids every year through UnitedHealthcare Hearing. Includes hearing aids delivered directly to you with virtual follow-up care (select models). |
|
| Annual Routine Physical Annual Routine Physical 4 $0 copay; 1 per year30% of the cost; combined visits In and Out of Network | $0 copay; 1 per year | 30% of the cost; combined visits In and Out of Network |
| Foot Care - Routine Foot Care - Routine 3 $0 copay; 8 visits per year30% of the cost; combined visits In and Out of Network | $0 copay; 8 visits per year | 30% of the cost; combined visits In and Out of Network |
| Naturopathy Services Naturopathy Services No CoverageNo Coverage | No Coverage | No Coverage |
| Over-the-Counter (OTC) Products Card Over-the-Counter (OTC) Products Card 4 $275 credit per quarter to buy covered OTC products.$275 credit per quarter to buy covered OTC products. | $275 credit per quarter to buy covered OTC products. | |
| Transportation Transportation $0 copay for 36 one-way trips to or from plan approved locations.75% of the cost | $0 copay for 36 one-way trips to or from plan approved locations. | 75% of the cost |
| Virtual Medical Visits Virtual Medical Visits $0 copay; Speak to network telehealth providers using your computer or mobile device.$0 copay; Speak to network telehealth providers using your computer or mobile device. | $0 copay; Speak to network telehealth providers using your computer or mobile device. | |
| Virtual Mental Health Visits Virtual Mental Health Visits $0 copay; Speak to network telehealth providers using your computer or mobile device.$0 copay; Speak to network telehealth providers using your computer or mobile device. | $0 copay; Speak to network telehealth providers using your computer or mobile device. | |
Important documents that provide the details you need about this plan's coverage and benefits, prescription drugs, enrollment, providers and more.
| General Plan Information | |
| Medical Providers | |
| Prescription Drug Coverage | |
| Pharmacy Directory |
1 The amount shown does not include the Part B premium you already pay to the government. Your plan costs, including premiums and drug costs, may be different if you get Extra Help from the government or if you have Medicaid. For more information, see "Can I Get Help with my Medicare Prescription Drug Costs?."
Benefits, premium and/or copayments/coinsurance may change on January 1 of each year.
2 Amounts may vary depending on the level of care provided or the type of health care services you receive.
3 Benefits, features and/or devices may vary by plan/area. Limitations and exclusions apply. See the Summary of Benefits (PDF) in the Plan Documents section for details.
4 Benefits, features and/or devices may vary by plan/area. Limitations and exclusions apply. See the Evidence of Coverage (PDF) in the Plan Documents section for details.
5 This document is the Annual Notice of Changes for this plan. If you are a current plan member and have been switched to a different plan, this document may not apply to you. If you have any questions, please call Customer Service at the number on your member ID card.
7 Coverage Gap Stage:
NOTE: Only applies to plans with prescription drug coverage.
Amounts displayed do not include taxes or injection fees.
During the Coverage Gap, amounts displayed for brand name drugs include a 70% manufacturer discount. However, this discount is based on pharmaceutical manufacturers' participation and may not apply to all brand drugs. You pay 25% of the total cost for brand name drugs, for any drug tier during the Coverage Gap.
The 25% drug coinsurance within the Coverage Gap is based on an assessment that the drug is defined as a generic drug according to Part D rules.
If your drug is not eligible for coverage under Medicare Part D, you will pay the full cost of the drug.
8 Optum Mail Home Delivery:
NOTE: Only applies to plans with prescription drug coverage.
2023 Savings Benefit
Savings apply during the Initial Coverage period, which begins after the payment of your required deductible (if any) and ends when the total cost of your drugs (paid by UnitedHealthcare, you and others) reaches $4,660.
OptumRx is an affiliate of UnitedHealthcare Insurance Company. Optum Home Delivery is a service of OptumRx pharmacy. You are not required to use Optum Home Delivery to obtain at least a 3-month supply of your maintenance medication. If you have not used Optum Home Delivery, you must approve the first prescription order sent directly from your doctor to OptumRx before it can be filled. New prescriptions from the pharmacy should arrive within ten business days from the date the completed order is received, and refill orders should arrive in about seven business days. Contact OptumRx anytime at 1-877-266-4832 (TTY 711).
$0 copays may be restricted to preferred home delivery prescriptions during the initial coverage phase and may not apply during the coverage or catastrophic stage. Benefits vary by plan/area. Limitations and exclusions apply.
Preferred Provider Organization (PPO) plans offer you the option to receive care from out-of-network providers; however, you will generally have a higher copay or higher coinsurance if you choose to go out-of-network. 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 cost-sharing that applies to out-of-network services.
Point of Service (POS) plans offer you the option to receive care from out-of-network providers; however, you will generally have a higher copay or higher coinsurance if you choose to go out-of-network.
Find important information about Medicare Advantage coverage determinations and appeals, quality assurance policies, grievances, drug conditions and limitations. View Medicare Advantage (Part C) coverage determinations and appeals process.
Learn about prescription drug coverage determinations and appeals, prior authorization criteria, step therapy criteria and the 60-day formulary change notice. View prescription drug (Part D) coverage determinations and appeals process.
View the UnitedHealthcare Prescription Drug Transition Process.
The list of covered drugs was last updated on 02/01/2023.
NOTE: Prescription drugs that are not covered by the plan or that cannot be provided as part of standard Medicare prescription drug coverage are shown as "not covered".
Copay or coinsurance amounts may change if you have a limited income.
The drug costs displayed are estimates and may vary based on the specific quantity, strength and/or dosage of the medication and the pharmacy you use. It may be important to look beyond your current needs at the value of having Medicare prescription drug insurance. Enrolling when you become eligible will help give you peace of mind, should your drug needs become more significant in the future. It may also help you avoid the Medicare late enrollment penalty.
Drugs and prices may vary between pharmacies and are subject to change during the plan year. Prices are based on quantity filled at the pharmacy. Quantities may be limited by pharmacy based on their dispensing policy or by the plan based on Quantity Limit requirements; if prescription is in excess of a limit, copay amounts may be higher.
The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
All network pharmacies may not be listed in this directory. Inclusion of a pharmacy does not guarantee that the pharmacy is open, is at the same location as listed in this online directory or is included in the network. The pharmacy network may change at any time. You will receive notice when necessary. Pharmacies on this list are called “network pharmacies” because UnitedHealthcare has made arrangements with them to provide prescription drugs to Plan members. In most cases, your prescriptions are covered under your plan only if they are filled at a network pharmacy or through our mail order pharmacy service. You are not required to continue using the same pharmacy to fill your prescriptions and may switch to any other network pharmacy. Prescriptions can be filled at non-network pharmacies under certain circumstances as described in your Evidence of Coverage. To get a complete description of your prescription coverage, including how to fill your prescriptions, please review the Evidence of Coverage and your plan’s formulary. Please contact UnitedHealthcare for details.
UnitedHealthcare has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area.
The pharmacy directory is current as of the first Sunday of each month.
NOTE: If you are receiving Extra Help from Medicare, your copays may be lower or you may have no copays.
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. For Dual Special Needs Plans: A Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in these plans depends on the plan’s contract renewal with Medicare.
Dental (Routine/Comprehensive): Benefits vary by plan/area. Limitations and exclusions apply. If your plan offers out-of-network dental coverage and you see an out-of-network dentist, you might be billed more. Network size varies by local market.
Fitbit: Choose one device from approved select models every 2 years. Devices may vary by plan/area. Limitations and exclusions apply. Fitbit, the Fitbit logo, and related marks and logos are trademarks of Google LLC and/or its affiliates.
Flex Card: Benefits and features vary by plan/area. Limitations and exclusions apply.Flex benefit allowance expires at the end of the plan year.Flex benefit allowance must be used at dental, vision or hearing providers that accept Visa.
Hearing: Benefits, features, and/or devices vary by plan/area. Limitations and exclusions may apply. Other hearing exam providers are available in the UnitedHealthcare network. The plan only covers hearing aids from a UnitedHealthcare Hearing network provider.
Network: Network size varies by plan and market. Benefits, features and/or devices vary by plan/area. Limitations and exclusions apply.
Over-the-Counter (OTC): Benefits and features vary by plan/area. Limitations and exclusions apply. Food, OTC and utility benefits have expiration timeframes. Call your plan or review your Evidence of Coverage (EOC) for more information.
PERS: Benefits, features and/or devices vary by plan/area. Limitations and exclusions apply. You must have a working landline and/or cellular phone coverage to use PERS.
Renew Active: Participation in the Renew Active®program is voluntary. Consult your doctor prior to beginning an exercise program. Renew Active includes standard fitness membership and other offerings.
Fitness membership equipment, classes, personalized fitness plans, caregiver access and events may vary by location. Certain services, discounts, classes, events and online fitness offerings are provided by affiliates of UnitedHealthcare Insurance Company or other third parties not affiliated with UnitedHealthcare. Participation in these third-party services are subject to your acceptance of their respective terms and policies. UnitedHealthcare is not responsible for the services or information provided by third parties. The information provided through these services is for informational purposes only and is not a substitute for the advice of a doctor. Gym network may vary in local market.
Vision: Vision benefits vary by plan and are not available with all plans. Limitations and exclusions apply. Additional charges may apply for out-of-network items and services.
This information is not a complete description of benefits. Call us for more information.
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。
Every year, Medicare evaluates plans based on a 5-star rating system.
UnitedHealthcare Senior Care Options is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare and does not have any other comprehensive health insurance, except Medicare. If you have MassHealth Standard, but you do not qualify for Original Medicare, you may still be eligible to enroll in our MassHealth Senior Care Option plan and receive all of your MassHealth benefits through our Senior Care Options program.
UnitedHealthcare Connected (Medicare - Medicaid Plan) is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees.
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