See how much you'll pay for this plan including your premium, deductible and maximum out-of-pocket costs.
In-network Out-of-network| Costs | In-network - What you'll pay | Out-of-network - What you'll pay |
|---|---|---|
| Monthly premium | $0 | |
| Monthly premium $0 $0 | ||
| 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. x Close Popup
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. x Close Popup
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. x Close Popup
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. x Close Popup
National Network As a member of an eligible health plan, the UnitedHealthcare Medicare National Network allows you to have access to participating care providers across the United States at your in-network cost share, even when getting care outside of your home location. Networks vary by market and exclusions may apply. x Close Popup
National Network As a member of an eligible health plan, the UnitedHealthcare Medicare National Network allows you to have access to participating care providers across the United States at your in-network cost share, even when getting care outside of your home location. Networks vary by market and exclusions may apply. x Close Popup
UnitedHealth Passport® travel benefit (PDF) UnitedHealthcare Passport® provides network costs and benefits of your plan when you travel. Networks vary by market and exclusions may apply. x Close Popup
UnitedHealth Passport® travel benefit (PDF) UnitedHealthcare Passport® provides network costs and benefits of your plan when you travel. Networks vary by market and exclusions may apply. x Close Popup
Find out about this plan’s copays for primary care providers and specialists.
In-network Out-of-network| Costs | In-network - what you'll pay | Out-of-network - what you'll pay |
|---|---|---|
| Primary care provider (PCP) | Tier 1: $0 copay Tier 2: $20 copay | 50% of the cost |
| Primary care provider (PCP) Tier 1: $0 copay Tier 2: $20 copay 50% of the cost | ||
| Specialist | Tier 1: $40 copay Tier 2: $55 copay | 50% of the cost |
| Specialist Tier 1: $40 copay Tier 2: $55 copay 50% of the cost | ||
| Virtual visits | $0 copay to talk with a telehealth provider online through live audio and video. | |
| Virtual visits $0 copay to talk with a telehealth provider online through live audio and video. $0 copay to talk with a telehealth provider online through live audio and video. | ||
| Annual routine physical | $0 copay, 1 per year | 50% of the cost, combined visits in and out-of-network |
| Annual routine physical $0 copay, 1 per year 50% of the cost, combined visits in and out-of-network | ||
| Preventive services (such as covered screenings, vaccinations, etc.) | $0 copay for covered services | $0 copay - 50% of the cost (depending on the service) |
| Preventive services (such as covered screenings, vaccinations, etc.) $0 copay for covered services $0 copay - 50% of the cost (depending on the service) | ||
| Mental health (outpatient) | Group: $15 copay Individual: $25 copay | Group: $30 copay Individual: $40 copay |
| Mental health (outpatient) Group: $15 copay Individual: $25 copay Group: $30 copay Individual: $40 copay | ||
| Opioid treatment services | $0 copay | $0 copay |
| Opioid treatment services $0 copay $0 copay | ||
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 |
|---|---|
| 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. x Close Popup
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. x Close Popup
Learn about this plan’s dental coverage options and costs.
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.
In-network Out-of-network| Costs | In-network - What you'll pay | Out-of-network - What you'll pay |
|---|---|---|
| Urgent care | $40 copay per visit ($0 copay when outside of the United States) | |
| Urgent care $40 copay per visit ($0 copay when outside of the United States) $40 copay per visit ($0 copay when outside of the United States) | ||
| Emergency care | $100 copay per visit ($0 copay when outside of the United States) | |
| Emergency care $100 copay per visit ($0 copay when outside of the United States) $100 copay per visit ($0 copay when outside of the United States) | ||
| Ambulance services | $275 copay for ground or air | $275 copay for ground or air |
| Ambulance services $275 copay for ground or air $275 copay for ground or air | ||
| Inpatient hospital care | $390 copay per day: days 1-4 $0 copay per day after that for unlimited days | 50% per stay for unlimited days |
| Inpatient hospital care $390 copay per day: days 1-4 $0 copay per day after that for unlimited days 50% per stay for unlimited days | ||
| Outpatient hospital services (including surgery and observation) | $390 copay | 50% of the cost |
| Outpatient hospital services (including surgery and observation) $390 copay 50% of the cost | ||
| Ambulatory surgical center | Tier 1: $340 copay Tier 2: $450 copay | 50% of the cost |
| Ambulatory surgical center Tier 1: $340 copay Tier 2: $450 copay 50% of the cost | ||
| Physical, speech or occupational therapy | $25 copay per visit | 50% of the cost per visit |
| Physical, speech or occupational therapy $25 copay per visit 50% of the cost per visit | ||
| Lab services | $0 copay | $0 copay |
| Lab services $0 copay $0 copay | ||
| Outpatient X-rays | $35 copay | $50 copay |
| Outpatient X-rays $35 copay $50 copay | ||
| Diagnostic tests and procedures, non-radiological (such as EKG/ECG tests, etc.) | $45 copay | 50% of the cost |
| Diagnostic tests and procedures, non-radiological (such as EKG/ECG tests, etc.) $45 copay 50% of the cost | ||
| Diagnostic radiology services (such as MRIs, CT scans, etc.) | $200 copay | 50% of the cost |
| Diagnostic radiology services (such as MRIs, CT scans, etc.) $200 copay 50% of the cost | ||
| Skilled nursing facility | $0 copay per day: days 1-20 $203 copay per day: days 21-100 | 50% of the cost |
| Skilled nursing facility $0 copay per day: days 1-20 $203 copay per day: days 21-100 50% of the cost | ||
| Home health care | $0 copay | 50% of the cost |
| Home health care $0 copay 50% of the cost | ||
| Diabetes monitoring supplies | $0 copay for covered brands | 50% of the cost |
| Diabetes monitoring supplies $0 copay for covered brands 50% of the cost | ||
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.
In-network Out-of-network| Costs | In-network - What you'll pay | Out-of-network - What you'll pay |
|---|---|---|
| Routine eye exam | $0 copay, 1 per year | 50% of the cost, combined visits in and out-of-network |
| Routine eye exam $0 copay, 1 per year 50% of the cost, combined visits in and out-of-network | ||
| Routine eyewear | $0 copay Plan pays up to $250 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 $250 every year for frames or contact lenses. Standard single, bifocal, trifocal, or progressive lenses are covered in full.
Important documents that provide the details you need about this plan's coverage and benefits, prescription drugs, enrollment, providers and more.
Other Languages1 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 (2024).
Optum Home Delivery Pharmacy and Optum Rx are affiliates of UnitedHealthcare Insurance Company. You are not required to use Optum Home Delivery Pharmacy for your regular medication. There may be other pharmacies in our network. If you have not used Optum Home Delivery Pharmacy, you must approve the first prescription order sent directly from your doctor 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 Home Delivery Pharmacy anytime at 1-877-266-4832 / TTY 711, 8 a.m. to 8 p.m., 7 days a week.
$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.
Dental, Ancilliary Mention:
Provider network may vary in local market. Dental network size based on Zelis Network360, May 2023.
D-SNP Disclaimer, State-Level Medicare:
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. 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.
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. UnitedHealthcare Insurance Company paid 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. AARP encourages you to consider your needs when selecting products and does not make specific product or pharmacy recommendations for individuals. UnitedHealthcare contracts directly with Walgreens for this plan; AARP and its affiliates are not parties to that contractual relationship.
Extra Help:
If you receive Extra Help from Medicare, your copays may be lower or you may have no copays.
Marketing Bullets:
- Benefits, features and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply.
- Nurse Hotline not for use in emergencies, for informational purposes only.
- Other hearing exam providers are available in the UnitedHealthcare network. The plan only covers hearing aids from a UnitedHealthcare Hearing network provider.
- For Chronic Special Needs Plans - You will pay a maximum of $25 for each 1-month supply of Part D covered insulin drug through all coverage stages, except the Catastrophic drug payment stage where you pay $0.
- 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, except the Catastrophic drug payment stage where you pay $0.
- Food, OTC and utility benefits have expiration timeframes. Call your plan or review your Evidence of Coverage (EOC) for more information.
- You must have a working landline and/or cellular phone coverage to use PERS.
- The fitness benefit includes a standard fitness membership. The information provided is for informational purposes only and is not medical advice. Consult your doctor prior to beginning an exercise program or making changes to your lifestyle or health care routine. Gym network may vary in local market and plan.
- 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.
- Routine transportation not for use in emergencies.
- Virtual visits may require video-enabled smartphone or other device. Not for use in emergencies. Not all network providers offer virtual care.
- $0 copays may be restricted to preferred home delivery prescriptions during the initial coverage phase and may not apply during the coverage gap or catastrophic stage. Optum® Home Delivery Pharmacy and Optum Rx are affiliates of the UnitedHealthcare Insurance Company. You are not required to use Optum Home Delivery Pharmacy for medications you take regularly. There may be other pharmacies in your network.
The Medicare Prescription Payment Plan:
Starting Jan. 1, 2025, if you spend more than $2,000 for 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.
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.
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 comuniquese con nuestro Servicio al Cliente.