Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID R1548-001-000
Plan Organization UnitedHealthcare
Plan Type Regional PPO
Plan Name UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)
Plan Organization Type Regional 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 4
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $30.60
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $30.60
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $7.70
Monthly Part D Premium 50% Assistance $15.30
Monthly Part D Premium 25% Assistance $23.00
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 40% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes No 40% coinsurance
Lab services - Out-of-Network Yes No $0 copay
Outpatient x-rays - Out-of-Network Yes No 40% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - 40% coinsurance per visit
Specialist - Out-of-Network Yes No 40% 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 40% coinsurance
Routine foot care Yes Out-of-Network Yes No 40% coinsurance
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 40% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $1,400 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 - 40% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 40% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 30% coinsurance
Other Part B drugs - Out-of-Network Yes - 30% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No $1,400 per stay
Outpatient group therapy visit - Out-of-Network Yes No 40% coinsurance
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No 40% coinsurance
Outpatient individual therapy visit - Out-of-Network Yes No 40% coinsurance
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No 40% 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 40% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 0-40% 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 40% coinsurance
Physical therapy and speech and language therapy visit - Out-of-Network Yes No 40% coinsurance
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 40% per stay
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 Yes Out-of-Network No No $0 copay
Eyeglass lenses Yes Out-of-Network No No $0 copay
Eyeglasses (frames and lenses) No - - - Not covered
Other No - - - Not covered
Routine eye exam Yes Out-of-Network Yes No 40% 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
Accomack County, Virginia, Alamance County, North Carolina, Albemarle County, Virginia, Alexander County, North Carolina, Alexandria City County, Virginia, Alleghany County, North Carolina, Alleghany County, Virginia, Amelia County, Virginia, Amherst County, Virginia, Anson County, North Carolina, Appomattox County, Virginia, Arlington County, Virginia, Ashe County, North Carolina, Augusta County, Virginia, Avery County, North Carolina, Bath County, Virginia, Beaufort County, North Carolina, Bedford County, Virginia, Bertie County, North Carolina, Bladen County, North Carolina, Bland County, Virginia, Botetourt County, Virginia, Bristol City County, Virginia, Brunswick County, North Carolina, Brunswick County, Virginia, Buchanan County, Virginia, Buckingham County, Virginia, Buena Vista City County, Virginia, Buncombe County, North Carolina, Burke County, North Carolina, Cabarrus County, North Carolina, Caldwell County, North Carolina, Camden County, North Carolina, Campbell County, Virginia, Caroline County, Virginia, Carroll County, Virginia, Carteret County, North Carolina, Caswell County, North Carolina, Catawba County, North Carolina, Charles City County, Virginia, Charlotte County, Virginia, Charlottesville City County, Virginia, Chatham County, North Carolina, Cherokee County, North Carolina, Chesapeake City County, Virginia, Chesterfield County, Virginia, Chowan County, North Carolina, Clarke County, Virginia, Clay County, North Carolina, Cleveland County, North Carolina, Colonial Heights City County, Virginia, Columbus County, North Carolina, Covington City County, Virginia, Craig County, Virginia, Craven County, North Carolina, Culpeper County, Virginia, Cumberland County, North Carolina, Cumberland County, Virginia, Currituck County, North Carolina, Danville City County, Virginia, Dare County, North Carolina, Davidson County, North Carolina, Davie County, North Carolina, Dickenson County, Virginia, Dinwiddie County, Virginia, Duplin County, North Carolina, Durham County, North Carolina, Edgecombe County, North Carolina, Emporia City County, Virginia, Essex County, Virginia, Fairfax City County, Virginia, Fairfax County, Virginia, Falls Church City County, Virginia, Fauquier County, Virginia, Floyd County, Virginia, Fluvanna County, Virginia, Forsyth County, North Carolina, Franklin City County, Virginia, Franklin County, North Carolina, Franklin County, Virginia, Frederick County, Virginia, Fredericksburg City County, Virginia, Galax City County, Virginia, Gaston County, North Carolina, Gates County, North Carolina, Giles County, Virginia, Gloucester County, Virginia, Goochland County, Virginia, Graham County, North Carolina, Granville County, North Carolina, Grayson County, Virginia, Greene County, North Carolina, Greene County, Virginia, Greensville County, Virginia, Guilford County, North Carolina, Halifax County, North Carolina, Halifax County, Virginia, Hampton City County, Virginia, Hanover County, Virginia, Harnett County, North Carolina, Harrisonburg City County, Virginia, Haywood County, North Carolina, Henderson County, North Carolina, Henrico County, Virginia, Henry County, Virginia, Hertford County, North Carolina, Highland County, Virginia, Hoke County, North Carolina, Hopewell City County, Virginia, Hyde County, North Carolina, Iredell County, North Carolina, Isle Of Wight County, Virginia, Jackson County, North Carolina, James City County, Virginia, Johnston County, North Carolina, Jones County, North Carolina, King And Queen County, Virginia, King George County, Virginia, King William County, Virginia, Lancaster County, Virginia, Lee County, North Carolina, Lee County, Virginia, Lenoir County, North Carolina, Lexington City County, Virginia, Lincoln County, North Carolina, Loudoun County, Virginia, Louisa County, Virginia, Lunenburg County, Virginia, Lynchburg City County, Virginia, Macon County, North Carolina, Madison County, North Carolina, Madison County, Virginia, Manassas City County, Virginia, Manassas Park City County, Virginia, Martin County, North Carolina, Martinsville City County, Virginia, Mathews County, Virginia, Mcdowell County, North Carolina, Mecklenburg County, North Carolina, Mecklenburg County, Virginia, Middlesex County, Virginia, Mitchell County, North Carolina, Montgomery County, North Carolina, Montgomery County, Virginia, Moore County, North Carolina, Nash County, North Carolina, Nelson County, Virginia, New Hanover County, North Carolina, New Kent County, Virginia, Newport News City County, Virginia, Norfolk City County, Virginia, Northampton County, North Carolina, Northampton County, Virginia, Northumberland County, Virginia, Norton City County, Virginia, Nottoway County, Virginia, Onslow County, North Carolina, Orange County, North Carolina, Orange County, Virginia, Page County, Virginia, Pamlico County, North Carolina, Pasquotank County, North Carolina, Patrick County, Virginia, Pender County, North Carolina, Perquimans County, North Carolina, Person County, North Carolina, Petersburg City County, Virginia, Pitt County, North Carolina, Pittsylvania County, Virginia, Polk County, North Carolina, Poquoson City County, Virginia, Portsmouth City County, Virginia, Powhatan County, Virginia, Prince Edward County, Virginia, Prince George County, Virginia, Prince William County, Virginia, Pulaski County, Virginia, Radford County, Virginia, Randolph County, North Carolina, Rappahannock County, Virginia, Richmond City County, Virginia, Richmond County, North Carolina, Richmond County, Virginia, Roanoke City County, Virginia, Roanoke County, Virginia, Robeson County, North Carolina, Rockbridge County, Virginia, Rockingham County, North Carolina, Rockingham County, Virginia, Rowan County, North Carolina, Russell County, Virginia, Rutherford County, North Carolina, Salem County, Virginia, Sampson County, North Carolina, Scotland County, North Carolina, Scott County, Virginia, Shenandoah County, Virginia, Smyth County, Virginia, Southampton County, Virginia, Spotsylvania County, Virginia, Stafford County, Virginia, Stanly County, North Carolina, Staunton City County, Virginia, Stokes County, North Carolina, Suffolk City County, Virginia, Surry County, North Carolina, Surry County, Virginia, Sussex County, Virginia, Swain County, North Carolina, Tazewell County, Virginia, Transylvania County, North Carolina, Tyrrell County, North Carolina, Union County, North Carolina, Vance County, North Carolina, Virginia Beach City County, Virginia, Wake County, North Carolina, Warren County, North Carolina, Warren County, Virginia, Washington County, North Carolina, Washington County, Virginia, Watauga County, North Carolina, Wayne County, North Carolina, Waynesboro City County, Virginia, Westmoreland County, Virginia, Wilkes County, North Carolina, Williamsburg City County, Virginia, Wilson County, North Carolina, Winchester City County, Virginia, Wise County, Virginia, Wythe County, Virginia, Yadkin County, North Carolina, Yancey County, North Carolina, York County, Virginia

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