Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H3256-001-000
Plan Organization UnitedHealthcare
Plan Type Local PPO
Plan Name UnitedHealthcare Dual Complete Choice LP (PPO D-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Defined Standard Benefit
Special Needs Plan Yes
Special Needs Plan Type Dual-Eligible
Overall Star Rating Plan too new to be measured
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $29.80
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $29.80
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $7.40
Monthly Part D Premium 50% Assistance $14.90
Monthly Part D Premium 25% Assistance $22.30
Part D Drug Deductible $445.00
Annual Drug Deductible $445.00
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00

Medicare Advantage Plan Health Benefits


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
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services Yes Out-of-Network Yes No $0 copay
Endodontics Yes Out-of-Network Yes No $0 copay
Extractions Yes Out-of-Network Yes No $0 copay
Non-routine services Yes Out-of-Network Yes No $0 copay
Periodontics Yes Out-of-Network Yes No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes No $0 copay
Restorative services Yes Out-of-Network Yes No $0 copay
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 30% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes No 30% coinsurance
Lab services - Out-of-Network Yes No $0 copay
Outpatient x-rays - Out-of-Network Yes No 30% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - 30% coinsurance per visit
Specialist - Out-of-Network Yes No 30% coinsurance per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $0 copay
Urgent care - - - - $0 copay
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network Yes No 30% coinsurance
Routine foot care Yes Out-of-Network Yes No $0 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - 20% coinsurance
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation No - - - Not covered
Hearing aids Yes Out-of-Network Yes No $0 copay
Hearing exam - Out-of-Network Yes No 30% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 30% per stay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $11,300 In and Out-of-network$7,550 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 30% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 30% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 30% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 20% coinsurance
Other Part B drugs - Out-of-Network Yes - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No 30% per stay
Outpatient group therapy visit - Out-of-Network Yes No 30% coinsurance
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No 30% coinsurance
Outpatient individual therapy visit - Out-of-Network Yes No 30% coinsurance
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No 30% coinsurance
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 30% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 0-30% coinsurance
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes Out-of-Network No No $0 copay
Dental x-ray(s) Yes Out-of-Network No No $0 copay
Fluoride treatment Yes Out-of-Network No No $0 copay
Oral exam 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 30% coinsurance
Physical therapy and speech and language therapy visit - Out-of-Network Yes No 30% coinsurance
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No Coming soon
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes Out-of-Network No No 75% coinsurance
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes Out-of-Network No No $0 copay
Eyeglass frames No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) Yes Out-of-Network No No $0 copay
Other No - - - Not covered
Routine eye exam Yes Out-of-Network Yes No 30% coinsurance
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Appling County, Georgia, Atkinson County, Georgia, Bacon County, Georgia, Baker County, Georgia, Baldwin County, Georgia, Banks County, Georgia, Barrow County, Georgia, Bartow County, Georgia, Ben Hill County, Georgia, 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, Camden County, Georgia, Candler County, Georgia, Catoosa County, Georgia, Charlton County, Georgia, Chatham County, Georgia, Chattahoochee County, Georgia, Chattooga County, Georgia, Cherokee County, Georgia, Clarke County, Georgia, Clay County, Georgia, Clayton County, Georgia, Clinch County, Georgia, Cobb County, Georgia, Coffee County, Georgia, Colquitt County, Georgia, Columbia County, Georgia, Cook County, Georgia, Coweta County, Georgia, Crawford County, Georgia, Crisp County, Georgia, Dade County, Georgia, Dawson County, Georgia, Decatur County, Georgia, Dekalb County, Georgia, Dodge County, Georgia, Dooly County, Georgia, Douglas County, Georgia, Early County, Georgia, Echols County, Georgia, Effingham County, Georgia, Elbert County, Georgia, Emanuel County, Georgia, Evans County, Georgia, Fannin County, Georgia, Fayette County, Georgia, Floyd County, Georgia, Forsyth County, Georgia, Franklin County, Georgia, Fulton County, Georgia, Gilmer County, Georgia, Glascock County, Georgia, Gordon County, Georgia, Grady County, Georgia, Greene County, Georgia, Gwinnett County, Georgia, Habersham County, Georgia, Hall County, Georgia, Hancock County, Georgia, Haralson County, Georgia, Harris County, Georgia, Hart County, Georgia, Heard County, Georgia, Henry County, Georgia, Houston County, Georgia, Irwin County, Georgia, Jackson County, Georgia, Jasper County, Georgia, Jeff Davis County, Georgia, Jefferson County, Georgia, Jenkins County, Georgia, Johnson County, Georgia, Jones County, Georgia, Lamar County, Georgia, Lanier County, Georgia, Laurens County, Georgia, Lincoln County, Georgia, Long County, Georgia, Lumpkin County, Georgia, Macon County, Georgia, Madison County, Georgia, Marion County, Georgia, 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, Newton County, Georgia, Oconee County, Georgia, Oglethorpe County, Georgia, Paulding County, Georgia, Peach County, Georgia, Pickens County, Georgia, Pike County, Georgia, Polk County, Georgia, Pulaski County, Georgia, Putnam County, Georgia, Quitman County, Georgia, Rabun County, Georgia, Randolph County, Georgia, Richmond County, Georgia, Rockdale County, Georgia, Schley County, Georgia, Screven County, Georgia, Seminole County, Georgia, Spalding County, Georgia, Stephens County, Georgia, Stewart County, Georgia, Sumter County, Georgia, Talbot County, Georgia, Taliaferro County, Georgia, Tattnall County, Georgia, Taylor County, Georgia, Telfair 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, 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, Wilcox County, Georgia, Wilkes County, Georgia, Wilkinson County, Georgia, Worth County, Georgia

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