Skip to main content
Toggle Menu


Services

Network

Non-Network

Services

Network

Non-Network

Deductible
  Per enrolled member

Network
Per enrolled member: $400 (only applies to services with coinsurance)

Non-Network
Combined with Network


$400 (only applies to services with coinsurance)


Combined with Network

Medical OOP Maximum
  Per enrolled member

Network
Per enrolled member: $2,500

Non-Network
Combined with Network


$2,500


Combined with Network

Physician Services — Copayments

Network
Primary Care: $15
Specialist: $30
Vitual Office Visit/Telemedicine: $0

Non-Network
Primary Care: $15
Specialist: $30
Vitual Office Visit/Telemedicine: $0

Primary Care: $15
Specialist: $30
Virtual Office Visit/Telemedicine: $0

Primary Care: $15
Specialist: $30
Virtual Office Visit/Telemedicine: $0

Inpatient Services — Copayments

Network
Inpatient Hospital/Mental Health: $350 Per Admit
Skilled Nursing Facility Care: $0 Per Day, Days 1-20,
$100 Per Day, Days 21-100

Non-Network
Inpatient Hospital/Mental Health: $350 Per Admit
Skilled Nursing Facility Care: $0 Per Day, Days 1-20,
$100 Per Day, Days 21-100

Inpatient Hospital/Mental Health: $350 Per Admit
Skilled Nursing Facility Care: $0 Per Day, Days 1-20,
$100 Per Day, Days 21-100

Inpatient Hospital/Mental Health: $350 Per Admit
Skilled Nursing Facility Care: $0 Per Day, Days 1-20,
$100 Per Day, Days 21-100

Urgent Care — Copayments

Network
$50

Non-Network
$50

$50

$50

Emergency Room — Copayments

Network
$100

Non-Network
$100

$100

$100

Prescription Drugs

See Medicare Prescription Drug Plan Benefit Chart

See Medicare Prescription Drug Plan Benefit Chart

See Medicare Prescription Drug Plan Benefit Chart

Part B Drugs

Network
20%

Non-Network
20%

20%

20%

This information is not a complete description of benefits. Limitations, copayments and restrictions may apply. To learn details about benefits, enrollment, accessing care and more, visit the UHC Website.

UnitedHealthcare® offers the Group Medicare Advantage (PPO) plan for medical coverage. Express Scripts provides the Medicare Prescription Drug Plan for prescription drug coverage to all Medicare-Eligible Non-Active members who are eligible retirees, terminated vested subscribers, or long-term disability subscribers and their eligible dependents who have Medicare.

Members will have a UnitedHealthcare® member ID card for medical coverage and an Express Scripts ID card for prescription drug coverage. You do not need to use your Original Medicare card or MCHCP ID card for your coverage.


Back to Top