Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID R2604-003-000
Plan Organization UnitedHealthcare
Plan Type Regional PPO
Plan Name UnitedHealthcare Medicare Gold (Regional PPO C-SNP)
Plan Organization Type Regional CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan Yes
Special Needs Plan Type Chronic or Disabling Condition
Conditions Covered Cardiovascular Disorders
Overall Star Rating 3.5 Stars
Plan Cost Sharing
Premium $13.00
Total Premium (Includes Part B) $148.50
Monthly Part D Basic Premium $13.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $13.00
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $3.20
Monthly Part D Premium 50% Assistance $6.50
Monthly Part D Premium 25% Assistance $9.70
Part D Drug Deductible $210.00
Annual Drug Deductible $210.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4020.00
Part D Catastrophic Coverage Threshold $6350.00
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services No - - - Not covered
Non-routine services Yes Out-of-Network Yes No 0-50%
Restorative services Yes In-Network Yes No 0-50%
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes No 0-50%
Endodontics No - - - Not covered
Extractions Yes Out-of-Network Yes No 0-50%
Periodontics Yes Out-of-Network Yes No 0-50%
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes No $0-100
Diagnostic tests and procedures - Out-of-Network Yes No $25
Lab services - Out-of-Network Yes No $0-14
Outpatient x-rays - In-Network Yes No $14
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - In-Network Yes No $0 copay
Routine foot care Yes In-Network Yes No $0 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $250
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - In-Network Yes - 20%
Other Part B drugs - In-Network Yes - 20%
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No $335 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient group therapy visit - Out-of-Network Yes No $30-40
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No $30-40
Outpatient individual therapy visit - Out-of-Network Yes No $30-40
Outpatient individual therapy visit with a psychiatrist - In-Network Yes No $40
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes No $0-335 per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Dental x-ray(s) Yes In-Network No No $0 copay
Oral exam Yes In-Network No No $0 copay
Cleaning Yes Out-of-Network No No $0 copay
Fluoride treatment Yes Out-of-Network No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes No $40
Physical therapy and speech and language therapy visit - In-Network Yes No $40
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes Out-of-Network No No 75%
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Eyeglass frames No - - - Not covered
Other No - - - Not covered
Eyeglasses (frames and lenses) Yes Out-of-Network No No $55 or 50%
Routine eye exam Yes Out-of-Network Yes No $0 copay
Upgrades - - - - Not covered
Contact lenses Yes Out-of-Network No No $55 or 50%
Eyeglass lenses No - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Hearing exam - Out-of-Network Yes No $40
Fitting/evaluation No - - - Not covered
Hearing aids Yes Out-of-Network Yes No $375
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - $55 or 50% per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 20% per item
Diabetes supplies - Out-of-Network Yes - 20% per item
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Specialist - In-Network Yes No $40 per visit
Primary - Out-of-Network - - $20 per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Urgent care - - - - $30-40 per visit (always covered)
Emergency - - - - $90 per visit (always covered)
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $335 per day for days 1 through 5 $0 per day for days 6 and beyond
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes No $0 per day for days 1 through 20 $160 per day for days 21 through 62 $0 per day for days 63 through 100
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $6,700 In and Out-of-network $6,700 In-network
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Abbeville County, South Carolina, Aiken County, South Carolina, Allendale County, South Carolina, Anderson County, South Carolina, Appling County, Georgia, Atkinson County, Georgia, Bacon County, Georgia, Baker County, Georgia, Baldwin County, Georgia, Bamberg County, South Carolina, Banks County, Georgia, Barnwell County, South Carolina, Barrow County, Georgia, Bartow County, Georgia, Beaufort County, South Carolina, Ben Hill County, Georgia, Berkeley County, South Carolina, Berrien County, Georgia, Bibb County, Georgia, Bleckley County, Georgia, Brantley County, Georgia, Brooks County, Georgia, Bryan County, Georgia, Bulloch County, Georgia, Burke County, Georgia, Butts County, Georgia, Calhoun County, Georgia, Calhoun County, South Carolina, Camden County, Georgia, Candler County, Georgia, Carroll County, Georgia, Catoosa County, Georgia, Charleston County, South Carolina, Charlton County, Georgia, Chatham County, Georgia, Chattahoochee County, Georgia, Chattooga County, Georgia, Cherokee County, Georgia, Cherokee County, South Carolina, Chester County, South Carolina, Chesterfield County, South Carolina, Clarendon County, South Carolina, Clarke County, Georgia, Clay County, Georgia, Clayton County, Georgia, Clinch County, Georgia, Cobb County, Georgia, Coffee County, Georgia, Colleton County, South Carolina, Colquitt County, Georgia, Columbia County, Georgia, Cook County, Georgia, Coweta County, Georgia, Crawford County, Georgia, Crisp County, Georgia, Dade County, Georgia, Darlington County, South Carolina, Dawson County, Georgia, Decatur County, Georgia, Dekalb County, Georgia, Dillon County, South Carolina, Dodge County, Georgia, Dooly County, Georgia, Dorchester County, South Carolina, Dougherty County, Georgia, Douglas County, Georgia, Early County, Georgia, Echols County, Georgia, Edgefield County, South Carolina, Effingham County, Georgia, Elbert County, Georgia, Emanuel County, Georgia, Evans County, Georgia, Fairfield County, South Carolina, Fannin County, Georgia, Fayette County, Georgia, Florence County, South Carolina, Floyd County, Georgia, Forsyth County, Georgia, Franklin County, Georgia, Fulton County, Georgia, Georgetown County, South Carolina, Gilmer County, Georgia, Glascock County, Georgia, Glynn County, Georgia, Gordon County, Georgia, Grady County, Georgia, Greene County, Georgia, Greenville County, South Carolina, Greenwood County, South Carolina, Gwinnett County, Georgia, Habersham County, Georgia, Hall County, Georgia, Hampton County, South Carolina, Hancock County, Georgia, Haralson County, Georgia, Harris County, Georgia, Hart County, Georgia, Heard County, Georgia, Henry County, Georgia, Horry County, South Carolina, Houston County, Georgia, Irwin County, Georgia, Jackson County, Georgia, Jasper County, Georgia, Jasper County, South Carolina, Jeff Davis County, Georgia, Jefferson County, Georgia, Jenkins County, Georgia, Johnson County, Georgia, Jones County, Georgia, Kershaw County, South Carolina, Lamar County, Georgia, Lancaster County, South Carolina, Lanier County, Georgia, Laurens County, Georgia, Laurens County, South Carolina, Lee County, Georgia, Lee County, South Carolina, Lexington County, South Carolina, Liberty County, Georgia, Lincoln County, Georgia, Long County, Georgia, Lowndes County, Georgia, Lumpkin County, Georgia, Macon County, Georgia, Madison County, Georgia, Marion County, Georgia, Marion County, South Carolina, Marlboro County, South Carolina, Mccormick County, South Carolina, Mcduffie County, Georgia, Mcintosh County, Georgia, Meriwether County, Georgia, Miller County, Georgia, Mitchell County, Georgia, Monroe County, Georgia, Montgomery County, Georgia, Morgan County, Georgia, Murray County, Georgia, Muscogee County, Georgia, Newberry County, South Carolina, Newton County, Georgia, Oconee County, Georgia, Oconee County, South Carolina, Oglethorpe County, Georgia, Orangeburg County, South Carolina, Paulding County, Georgia, Peach County, Georgia, Pickens County, Georgia, Pickens County, South Carolina, Pierce County, Georgia, Pike County, Georgia, Polk County, Georgia, Pulaski County, Georgia, Putnam County, Georgia, Quitman County, Georgia, Rabun County, Georgia, Randolph County, Georgia, Richland County, South Carolina, Richmond County, Georgia, Rockdale County, Georgia, Saluda County, South Carolina, Schley County, Georgia, Screven County, Georgia, Seminole County, Georgia, Spalding County, Georgia, Spartanburg County, South Carolina, Stephens County, Georgia, Stewart County, Georgia, Sumter County, Georgia, Sumter County, South Carolina, Talbot County, Georgia, Taliaferro County, Georgia, Tattnall County, Georgia, Taylor County, Georgia, Telfair County, Georgia, Terrell County, Georgia, Thomas County, Georgia, Tift County, Georgia, Toombs County, Georgia, Towns County, Georgia, Treutlen County, Georgia, Troup County, Georgia, Turner County, Georgia, Twiggs County, Georgia, Union County, Georgia, Union County, South Carolina, Upson County, Georgia, Walker County, Georgia, Walton County, Georgia, Ware County, Georgia, Warren County, Georgia, Washington County, Georgia, Wayne County, Georgia, Webster County, Georgia, Wheeler County, Georgia, White County, Georgia, Whitfield County, Georgia, Wilcox County, Georgia, Wilkes County, Georgia, Wilkinson County, Georgia, Williamsburg County, South Carolina, Worth County, Georgia, York County, South Carolina

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