| 2021 Medicare Advantage Plan Details | |||||
|---|---|---|---|---|---|
| Medicare Plan Name: | UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO) | ||||
| Location: | Schuyler, New York | ||||
| Plan ID: | R5342 - 001 - 0 Click to see other plans | ||||
| Member Services: | 1-800-711-6088 TTY users 711 | ||||
| — Enrollment Options — | |||||
| Medicare Contact Information: | 1-800-MEDICARE (1-800-633-4227) TTY users 1-877-486-2048 | ||||
Medicare plan advice at no cost from licensed insurance agents. Call: 888-205-9813 / TTY 711 Monday‐Friday 8am — 8pm ET | |||||
| Email a copy of the UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO) benefit details | |||||
| — Medicare Plan Features — | |||||
| Monthly Premium: | $16.00 (see Plan Premium Details below) | ||||
| Annual Deductible: | $300 (Tier Yes excluded from the Deductible.) | ||||
| Annual Initial Coverage Limit (ICL): | $4,130 | ||||
| Health Plan Type: | Regional PPO | ||||
| Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
| Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
| Total Number of Formulary Drugs: | 3,609 drugs | Browse the UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO) Formulary | |||
| This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||
| This plan offers select insulin at $35 or less. Learn more. | |||||
| Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
| • Preferred Pharmacy Cost-Sharing during initial coverage phase: | $3.00 | $12.00 | $47.00 | $100.00 | 27% |
| • Number of Drugs per Tier: | 303 | 675 | 867 | 1010 | 754 |
| Plan's Pharmacy Search: | http://www.UHCMedicareSolutions.com | ||||
| Plan Offers Mail Order? | Yes | ||||
| Number of Members enrolled in this plan in Schuyler, New York: | 185 members | ||||
| Number of Members enrolled in this plan in (R5342 - 001): | 92,636 members | ||||
| Plan's Summary Star Rating: | 4 out of 5 Stars. | ||||
| • Customer Service Rating: | 5 out of 5 Stars. | ||||
| • Member Experience Rating: | 3 out of 5 Stars. | ||||
| • Drug Cost Accuracy Rating: | 4 out of 5 Stars. | ||||
| — Plan Premium Details — | |||||
| The Monthly Premium is Split as Follows:❔ | Total Premium | Part C Premium | Part D Base Premium | Part D Supplemental Premium | |
| $16.00 | $0.00 | $16.00 | $0.00 | ||
| Monthly Premium with Extra Help Low-Income Subsidy (LIS):❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
| Monthly Part D Premium with LIS: | $0.00 | $4.00 | $8.00 | $12.00 | |
| Total Monthly Premium with LIS (Parts C & D): | $0.00 | $4.00 | $8.00 | $12.00 |
United Healthcare Medicaid Physical Therapy
| — Plan Health Benefits — |
| ** Base Plan ** |
| Premium |
| • Health plan premium: $0 |
| • Drug plan premium: $16 |
| • You must continue to pay your Part B premium. |
| • Part B premium reduction: No |
| Deductible |
| • Health plan deductible: $0 |
| • Other health plan deductibles: In-network: No |
| • Drug plan deductible: $300.00 annual deductible |
| Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) |
| • $10,000 In and Out-of-network $6,700 In-network |
| Optional supplemental benefits |
| • Yes |
| Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? |
| • In-network: No |
| Doctor visits |
| • Primary In-network: $0 copay |
| • Primary Out-of-network: $50 copay per visit |
| • Specialist In-network: $45 copay per visit (authorization required) |
| • Specialist Out-of-network: $75 copay per visit (authorization required) |
| Diagnostic procedures/lab services/imaging |
| • Diagnostic tests and procedures In-network: $30 copay (authorization required) |
| • Diagnostic tests and procedures Out-of-network: 40% coinsurance (authorization required) |
| • Lab services In-network: $0 copay (authorization required) |
| • Lab services Out-of-network: $0 copay (authorization required) |
| • Diagnostic radiology services (e.g., MRI) In-network: $0-160 copay (authorization required) |
| • Diagnostic radiology services (e.g., MRI) Out-of-network: 40% coinsurance (authorization required) |
| • Outpatient x-rays In-network: $50 copay (authorization required) |
| • Outpatient x-rays Out-of-network: $50 copay (authorization required) |
| Emergency care/Urgent care |
| • Emergency: $90 copay per visit (always covered) |
| • Urgent care: $30-40 copay per visit (always covered) |
| Inpatient hospital coverage |
| • In-network: $375 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 91 and beyond (authorization required) |
| • Out-of-network: $500 per day for days 1 through 20 $0 per day for days 21 and beyond (authorization required) |
| Outpatient hospital coverage |
| • In-network: $0-325 copay per visit (authorization required) |
| • Out-of-network: 40% coinsurance per visit (authorization required) |
| Skilled Nursing Facility |
| • In-network: $0 per day for days 1 through 20 $184 per day for days 21 through 57 $0 per day for days 58 through 100 (authorization required) |
| • Out-of-network: $225 per day for days 1 through 45 $0 per day for days 46 through 100 (authorization required) |
| Preventive care |
| • In-network: $0 copay |
| • Out-of-network: 0-40% coinsurance |
| Ground ambulance |
| • In-network: $250 copay |
| • Out-of-network: $250 copay |
| Rehabilitation services |
| • Occupational therapy visit In-network: $40 copay (authorization required) |
| • Occupational therapy visit Out-of-network: $75 copay (authorization required) |
| • Physical therapy and speech and language therapy visit In-network: $40 copay (authorization required) |
| • Physical therapy and speech and language therapy visit Out-of-network: $75 copay (authorization required) |
| Mental health services |
| • Inpatient hospital - psychiatric In-network: $375 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) |
| • Inpatient hospital - psychiatric Out-of-network: $500 per day for days 1 through 20 $0 per day for days 21 through 90 (authorization required) |
| • Outpatient group therapy visit with a psychiatrist In-network: $15 copay (authorization required) |
| • Outpatient group therapy visit with a psychiatrist Out-of-network: $30-40 copay (authorization required) |
| • Outpatient individual therapy visit with a psychiatrist In-network: $25 copay (authorization required) |
| • Outpatient individual therapy visit with a psychiatrist Out-of-network: $30-40 copay (authorization required) |
| • Outpatient group therapy visit In-network: $15 copay (authorization required) |
| • Outpatient group therapy visit Out-of-network: $30-40 copay (authorization required) |
| • Outpatient individual therapy visit In-network: $25 copay (authorization required) |
| • Outpatient individual therapy visit Out-of-network: $30-40 copay (authorization required) |
| Medical equipment/supplies |
| • Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 20% coinsurance per item (authorization required) |
| • Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 50% coinsurance per item (authorization required) |
| • Prosthetics (e.g., braces, artificial limbs) In-network: 20% coinsurance per item (authorization required) |
| • Prosthetics (e.g., braces, artificial limbs) Out-of-network: 40% coinsurance per item (authorization required) |
| • Diabetes supplies In-network: $0 copay per item (authorization required) |
| • Diabetes supplies Out-of-network: 40% coinsurance per item (authorization required) |
| Hearing |
| • Hearing exam In-network: $0 copay (authorization required) |
| • Hearing exam Out-of-network: $75 copay (authorization required) |
| • Fitting/evaluation: Not covered |
| • Hearing aids In-network: $375-2,075 copay (limits apply, authorization required) |
| • Hearing aids Out-of-network: $375 copay (limits apply, authorization required) |
| Preventive dental |
| • Oral exam In-network: $0 copay (limits apply) |
| • Oral exam Out-of-network: $0 copay (limits apply) |
| • Cleaning In-network: $0 copay (limits apply) |
| • Cleaning Out-of-network: $0 copay (limits apply) |
| • Fluoride treatment In-network: $0 copay (limits apply) |
| • Fluoride treatment Out-of-network: $0 copay (limits apply) |
| • Dental x-ray(s) In-network: $0 copay (limits apply) |
| • Dental x-ray(s) Out-of-network: $0 copay (limits apply) |
| Comprehensive dental |
| • Non-routine services: Not covered |
| • Diagnostic services: Not covered |
| • Restorative services: Not covered |
| • Endodontics: Not covered |
| • Periodontics: Not covered |
| • Extractions: Not covered |
| • Prosthodontics, other oral/maxillofacial surgery, other services: Not covered |
| Vision |
| • Routine eye exam In-network: $0 copay (limits apply, authorization required) |
| • Routine eye exam Out-of-network: $75 copay (limits apply, authorization required) |
| • Other: Not covered |
| • Contact lenses In-network: $0 copay (limits apply) |
| • Contact lenses Out-of-network: $0 copay (limits apply) |
| • Eyeglasses (frames and lenses) In-network: $0 copay (limits apply) |
| • Eyeglasses (frames and lenses) Out-of-network: $0 copay (limits apply) |
| • Eyeglass frames: Not covered |
| • Eyeglass lenses: Not covered |
| • Upgrades: Not covered |
| Wellness programs (e.g., fitness, nursing hotline) |
| • Covered |
| Transportation |
| • Not covered |
| Foot care (podiatry services) |
| • Foot exams and treatment In-network: $45 copay (authorization required) |
| • Foot exams and treatment Out-of-network: $75 copay (authorization required) |
| • Routine foot care In-network: $45 copay (limits apply, authorization required) |
| • Routine foot care Out-of-network: $75 copay (limits apply, authorization required) |
| Medicare Part B drugs |
| • Chemotherapy In-network: 20% coinsurance (authorization required) |
| • Chemotherapy Out-of-network: 40% coinsurance (authorization required) |
| • Other Part B drugs In-network: 20% coinsurance (authorization required) |
| • Other Part B drugs Out-of-network: 40% coinsurance (authorization required) |
| Package #1 |
| • Monthly Premium: $40.00 |
| • Deductible: |
| — Plan Health Benefits — |
| ** Base Plan ** |
| Premium |
| • Health plan premium: $0 |
| • Drug plan premium: $16 |
| • You must continue to pay your Part B premium. |
| • Part B premium reduction: No |
| Deductible |
| • Health plan deductible: $0 |
| • Other health plan deductibles: In-network: No |
| • Drug plan deductible: $300.00 annual deductible |
| Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) |
| • $10,000 In and Out-of-network $6,700 In-network |
| Optional supplemental benefits |
| • Yes |
| Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? |
| • In-network: No |
| Doctor visits |
| • Primary In-network: $0 copay |
| • Primary Out-of-network: $50 copay per visit |
| • Specialist In-network: $45 copay per visit (authorization required) |
| • Specialist Out-of-network: $75 copay per visit (authorization required) |
| Diagnostic procedures/lab services/imaging |
| • Diagnostic tests and procedures In-network: $30 copay (authorization required) |
| • Diagnostic tests and procedures Out-of-network: 40% coinsurance (authorization required) |
| • Lab services In-network: $0 copay (authorization required) |
| • Lab services Out-of-network: $0 copay (authorization required) |
| • Diagnostic radiology services (e.g., MRI) In-network: $0-160 copay (authorization required) |
| • Diagnostic radiology services (e.g., MRI) Out-of-network: 40% coinsurance (authorization required) |
| • Outpatient x-rays In-network: $50 copay (authorization required) |
| • Outpatient x-rays Out-of-network: $50 copay (authorization required) |
| Emergency care/Urgent care |
| • Emergency: $90 copay per visit (always covered) |
| • Urgent care: $30-40 copay per visit (always covered) |
| Inpatient hospital coverage |
| • In-network: $375 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 91 and beyond (authorization required) |
| • Out-of-network: $500 per day for days 1 through 20 $0 per day for days 21 and beyond (authorization required) |
| Outpatient hospital coverage |
| • In-network: $0-325 copay per visit (authorization required) |
| • Out-of-network: 40% coinsurance per visit (authorization required) |
| Skilled Nursing Facility |
| • In-network: $0 per day for days 1 through 20 $184 per day for days 21 through 57 $0 per day for days 58 through 100 (authorization required) |
| • Out-of-network: $225 per day for days 1 through 45 $0 per day for days 46 through 100 (authorization required) |
| Preventive care |
| • In-network: $0 copay |
| • Out-of-network: 0-40% coinsurance |
| Ground ambulance |
| • In-network: $250 copay |
| • Out-of-network: $250 copay |
| Rehabilitation services |
| • Occupational therapy visit In-network: $40 copay (authorization required) |
| • Occupational therapy visit Out-of-network: $75 copay (authorization required) |
| • Physical therapy and speech and language therapy visit In-network: $40 copay (authorization required) |
| • Physical therapy and speech and language therapy visit Out-of-network: $75 copay (authorization required) |
| Mental health services |
| • Inpatient hospital - psychiatric In-network: $375 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) |
| • Inpatient hospital - psychiatric Out-of-network: $500 per day for days 1 through 20 $0 per day for days 21 through 90 (authorization required) |
| • Outpatient group therapy visit with a psychiatrist In-network: $15 copay (authorization required) |
| • Outpatient group therapy visit with a psychiatrist Out-of-network: $30-40 copay (authorization required) |
| • Outpatient individual therapy visit with a psychiatrist In-network: $25 copay (authorization required) |
| • Outpatient individual therapy visit with a psychiatrist Out-of-network: $30-40 copay (authorization required) |
| • Outpatient group therapy visit In-network: $15 copay (authorization required) |
| • Outpatient group therapy visit Out-of-network: $30-40 copay (authorization required) |
| • Outpatient individual therapy visit In-network: $25 copay (authorization required) |
| • Outpatient individual therapy visit Out-of-network: $30-40 copay (authorization required) |
| Medical equipment/supplies |
| • Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 20% coinsurance per item (authorization required) |
| • Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 50% coinsurance per item (authorization required) |
| • Prosthetics (e.g., braces, artificial limbs) In-network: 20% coinsurance per item (authorization required) |
| • Prosthetics (e.g., braces, artificial limbs) Out-of-network: 40% coinsurance per item (authorization required) |
| • Diabetes supplies In-network: $0 copay per item (authorization required) |
| • Diabetes supplies Out-of-network: 40% coinsurance per item (authorization required) |
| Hearing |
| • Hearing exam In-network: $0 copay (authorization required) |
| • Hearing exam Out-of-network: $75 copay (authorization required) |
| • Fitting/evaluation: Not covered |
| • Hearing aids In-network: $375-2,075 copay (limits apply, authorization required) |
| • Hearing aids Out-of-network: $375 copay (limits apply, authorization required) |
| Preventive dental |
| • Oral exam In-network: $0 copay (limits apply) |
| • Oral exam Out-of-network: $0 copay (limits apply) |
| • Cleaning In-network: $0 copay (limits apply) |
| • Cleaning Out-of-network: $0 copay (limits apply) |
| • Fluoride treatment In-network: $0 copay (limits apply) |
| • Fluoride treatment Out-of-network: $0 copay (limits apply) |
| • Dental x-ray(s) In-network: $0 copay (limits apply) |
| • Dental x-ray(s) Out-of-network: $0 copay (limits apply) |
| Comprehensive dental |
| • Non-routine services: Not covered |
| • Diagnostic services: Not covered |
| • Restorative services: Not covered |
| • Endodontics: Not covered |
| • Periodontics: Not covered |
| • Extractions: Not covered |
| • Prosthodontics, other oral/maxillofacial surgery, other services: Not covered |
| Vision |
| • Routine eye exam In-network: $0 copay (limits apply, authorization required) |
| • Routine eye exam Out-of-network: $75 copay (limits apply, authorization required) |
| • Other: Not covered |
| • Contact lenses In-network: $0 copay (limits apply) |
| • Contact lenses Out-of-network: $0 copay (limits apply) |
| • Eyeglasses (frames and lenses) In-network: $0 copay (limits apply) |
| • Eyeglasses (frames and lenses) Out-of-network: $0 copay (limits apply) |
| • Eyeglass frames: Not covered |
| • Eyeglass lenses: Not covered |
| • Upgrades: Not covered |
| Wellness programs (e.g., fitness, nursing hotline) |
| • Covered |
| Transportation |
| • Not covered |
| Foot care (podiatry services) |
| • Foot exams and treatment In-network: $45 copay (authorization required) |
| • Foot exams and treatment Out-of-network: $75 copay (authorization required) |
| • Routine foot care In-network: $45 copay (limits apply, authorization required) |
| • Routine foot care Out-of-network: $75 copay (limits apply, authorization required) |
| Medicare Part B drugs |
| • Chemotherapy In-network: 20% coinsurance (authorization required) |
| • Chemotherapy Out-of-network: 40% coinsurance (authorization required) |
| • Other Part B drugs In-network: 20% coinsurance (authorization required) |
| • Other Part B drugs Out-of-network: 40% coinsurance (authorization required) |
| Package #1 |
| • Monthly Premium: $40.00 |
| • Deductible: |
At UnitedHealthcare, we are committed to improving the health care system. UnitedHealthcare is an operating division of UnitedHealth Group, the largest single health carrier in.
United Healthcare Physical Therapy Policy
With this new benefit design, plan participants enrolled in certain employer-sponsored health plans can pay $0 out of pocket (waived deductible or copay) if they select physical therapy or chiropractic care for the treatment of low back pain, helping encourage people to choose these noninvasive options. All UnitedHealthcare Medicare Advantage plans have an annual out-of-pocket maximum for covered medical benefits. Copays and coinsurance may vary depending on the member's plan. Group Retiree plans may have different copays and coinsurance. Occupational Therapy and/or Physical Therapy evaluation and treatment services are considered Medically Necessary when a member meets all of the following criteria: The member exhibits signs and symptoms of a Functional or Physical Impairment as evidenced by the inability to perform. All UnitedHealthcare Medicare Advantage plans have an annual out-of-pocket maximum for covered medical benefits. Copays and coinsurance may vary depending on the member's plan. Group Retiree plans may have different copays and coinsurance.
