Medicare-eligible members who are eligible retirees, terminated vested subscribers, long-term disability subscribers, survivors, and eligible dependents
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.
Deductible
Per enrolled member
Network
Per enrolled member: $300 (only applies to services with coinsurance)
Non-Network
Combined with Network
$300 (only applies to services with coinsurance)
Combined with Network
Medical OOP Maximum
Per enrolled member
Network
Per enrolled member: $1,500
Non-Network
Combined with Network
$1,500
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: $150 Per Admit
Skilled Nursing Facility Care: $0 Per Day, Days 1-100,
Non-Network
Inpatient Hospital/Mental Health: $350 Per Admit
Skilled Nursing Facility Care: $0 Per Day, Days 1-20,
Inpatient Hospital/Mental Health: $150 Per Admit
Skilled Nursing Facility Care: $0 Per Day, Days 1-100
Inpatient Hospital/Mental Health: $150 Per Admit
Skilled Nursing Facility Care: $0 Per Day, Days 1-100
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%
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.
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