UnitedHealthcare Dual Complete ONE (HMO D-SNP)

Footnotes

 

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. 

 

⁶ 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. 

 

2024 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 $5,030. 

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.

 

Optum Rx is an affiliate of UnitedHealthcare Insurance Company. Optum Home Delivery is a service of Optum Rx 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 Optum Rx 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 Optum Rx 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.  

 

Disclaimers 

 

PPO plans: 

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. 

 

Coverage determinations and appeals process

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. 

 

Information for plans with prescription drug coverage

 

The list of covered drugs was last updated on 12/01/2023. 

 

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. 

 

Enrollment disclaimer information

 

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies.. For Medicare Advantage plans: A Medicare Advantage organization with a Medicare contract. 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, features and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may 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. Provider network may vary in local market. Dental network size based on Zelis Network360, May 2023. 

 

Hearing: 

Benefits, features, and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply. Other hearing exam providers are available in the UnitedHealthcare network. The plan only covers hearing aids from a UnitedHealthcare Hearing network provider. Provider network size may vary by local market. 

 

Network:

Provider network may vary in local market. Provider network size based on Zelis Network360, May 2023. 

 

Over-the-Counter (OTC):  

Benefits, features and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply. Food/OTC/Utilities 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, exclusions and/or network restrictions may apply. You must have a working landline and/or cellular phone coverage to use PERS.

 

Renew Active:

The Renew Active® Program varies by plan/area and may not be available on all plans. Participation in the Renew Active program is voluntary. Consult your doctor prior to beginning an exercise program or making changes to your lifestyle or health care routine. 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 and plan. Gym network size is based on comparison of competitor’s website data as of May 2023.

 

Transportation:

Benefits, features and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply. Routine transportation not for use in emergencies.

 

Vision: 

Benefits, features and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply. Additional charges may apply for out-of-network items and services. Provider and retail network may vary in local market. Vision retail locations include retailer websites. Annual routine eye exam and $100-$400 allowance for contacts or designer frames, with standard (single, bi-focal, tri-focal or standard progressive) lenses covered in full either annually or every two years. Savings based on comparison to retail. Other vision providers are available in our network. 

 

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.

 

Texas disclaimer information

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. 

 

For 2024 plans:  This is a short description of your 2024 plan benefits. 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. 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.