Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H6528-006-000
Plan Organization UnitedHealthcare
Plan Type Local PPO
Plan Name UnitedHealthcare Medicare Advantage Choice Plan 1 (PPO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 3.5
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $0.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $0.00
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $0.00
Monthly Part D Premium 50% Assistance $0.00
Monthly Part D Premium 25% Assistance $0.00
Part D Drug Deductible $275.00
Annual Drug Deductible $275.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $6700.00
Gap Coverage No

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 0-50% coinsurance
Endodontics Yes Out-of-Network Yes No 0-50% coinsurance
Extractions Yes Out-of-Network Yes No 0-50% coinsurance
Non-routine services Yes Out-of-Network Yes No 0-50% coinsurance
Periodontics Yes Out-of-Network Yes No 0-50% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes No 0-50% coinsurance
Restorative services Yes Out-of-Network Yes No 0-50% coinsurance
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 $150-200 copay
Diagnostic tests and procedures - Out-of-Network Yes No $40 copay
Lab services - Out-of-Network Yes No $0 copay
Outpatient x-rays - Out-of-Network Yes No $20 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $30-60 copay per visit
Specialist - Out-of-Network Yes No $60 copay per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $30-40 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network Yes No $60 copay
Routine foot care Yes Out-of-Network Yes No $60 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $250 copay
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 $375 copay
Hearing exam - Out-of-Network Yes No $60 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $495 per day for days 1 through 10$0 per day for days 11 and beyond
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $10,000 In and Out-of-network$6,700 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 - 20-50% 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 - 40% coinsurance
Other Part B drugs - Out-of-Network Yes - 40% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No $495 per day for days 1 through 10$0 per day for days 11 through 90
Outpatient group therapy visit - Out-of-Network Yes No $30-40 copay
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No $30-40 copay
Outpatient individual therapy visit - Out-of-Network Yes No $30-40 copay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No $30-40 copay
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 $495 copay 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
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 $60 copay
Physical therapy and speech and language therapy visit - Out-of-Network Yes No $60 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $225 per day for days 1 through 45$0 per day for days 46 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
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 $60 copay
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
Baldwin County, Georgia, Banks County, Georgia, Barrow County, Georgia, Ben Hill County, Georgia, Bibb County, Georgia, Bryan County, Georgia, Bulloch County, Georgia, Chatham County, Georgia, Cherokee County, Georgia, Clarke County, Georgia, Clayton County, Georgia, Columbia County, Georgia, Coweta County, Georgia, Crawford County, Georgia, Crisp County, Georgia, Dawson County, Georgia, Dodge County, Georgia, Dooly County, Georgia, Douglas County, Georgia, Effingham County, Georgia, Emanuel County, Georgia, Evans County, Georgia, Fayette County, Georgia, Forsyth County, Georgia, Gwinnett County, Georgia, Habersham County, Georgia, Hall County, Georgia, Harris County, Georgia, Henry County, Georgia, Houston County, Georgia, Irwin County, Georgia, Jackson County, Georgia, Johnson County, Georgia, Laurens County, Georgia, Lumpkin County, Georgia, Macon County, Georgia, Montgomery County, Georgia, Muscogee County, Georgia, Newton County, Georgia, Oconee County, Georgia, Paulding County, Georgia, Peach County, Georgia, Pulaski County, Georgia, Richmond County, Georgia, Rockdale County, Georgia, Spalding County, Georgia, Stephens County, Georgia, Taylor County, Georgia, Telfair County, Georgia, Tift County, Georgia, Toombs County, Georgia, Towns County, Georgia, Treutlen County, Georgia, Turner County, Georgia, Twiggs County, Georgia, Union County, Georgia, Upson County, Georgia, Walton County, Georgia, White County, Georgia, Wilcox County, Georgia, Wilkinson County, Georgia

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