Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID R3444-012-000
Plan Organization UnitedHealthcare
Plan Type Regional PPO
Plan Name UnitedHealthcare Medicare Advantage Choice Plan 2 (Regional PPO)
Plan Organization Type Regional 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 $55.00
Total Premium (Includes Part B) $190.50
Monthly Part C Premium $15.00
Monthly Part D Basic Premium $40.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $40.00
Monthly Part D Premium Full Assistance $11.50
Monthly Part D Premium 75% Assistance $18.60
Monthly Part D Premium 50% Assistance $25.80
Monthly Part D Premium 25% Assistance $32.90
Part D Drug Deductible $295.00
Annual Drug Deductible $295.00
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 No - - - Not covered
Endodontics No - - - Not covered
Extractions No - - - Not covered
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services No - - - Not covered
Restorative services No - - - Not covered
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 $0-125 copay
Diagnostic tests and procedures - Out-of-Network Yes No $20 copay
Lab services - Out-of-Network Yes No $0 copay
Outpatient x-rays - Out-of-Network Yes No $15 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $25-50 copay per visit
Specialist - Out-of-Network Yes No $50 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 $50 copay
Routine foot care Yes Out-of-Network Yes No $50 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 $50 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $370 per day for days 1 through 5$0 per day for days 6 and beyond
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
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 45% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 20% 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 $370 per day for days 1 through 5$0 per day for days 6 through 90
Outpatient group therapy visit - Out-of-Network Yes No $15-25 copay
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No $15-25 copay
Outpatient individual therapy visit - Out-of-Network Yes No $15-25 copay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No $15-25 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Yes
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 $0-370 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 $40 copay
Physical therapy and speech and language therapy visit - Out-of-Network Yes No $40 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 30$0 per day for days 31 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 $20 copay
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered

Medicare Plan Packages


Package #1
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $40.00
Preventive dental Monthly Premium $40.00
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
Adair County, Missouri, Andrew County, Missouri, Arkansas County, Arkansas, Ashley County, Arkansas, Atchison County, Missouri, Audrain County, Missouri, Barry County, Missouri, Barton County, Missouri, Bates County, Missouri, Baxter County, Arkansas, Benton County, Arkansas, Benton County, Missouri, Bollinger County, Missouri, Boone County, Arkansas, Boone County, Missouri, Bradley County, Arkansas, Buchanan County, Missouri, Butler County, Missouri, Caldwell County, Missouri, Calhoun County, Arkansas, Callaway County, Missouri, Camden County, Missouri, Cape Girardeau County, Missouri, Carroll County, Arkansas, Carroll County, Missouri, Carter County, Missouri, Cass County, Missouri, Cedar County, Missouri, Chariton County, Missouri, Chicot County, Arkansas, Christian County, Missouri, Clark County, Arkansas, Clark County, Missouri, Clay County, Arkansas, Clay County, Missouri, Cleburne County, Arkansas, Cleveland County, Arkansas, Clinton County, Missouri, Cole County, Missouri, Columbia County, Arkansas, Conway County, Arkansas, Cooper County, Missouri, Craighead County, Arkansas, Crawford County, Arkansas, Crawford County, Missouri, Crittenden County, Arkansas, Cross County, Arkansas, Dade County, Missouri, Dallas County, Arkansas, Dallas County, Missouri, Daviess County, Missouri, Dekalb County, Missouri, Dent County, Missouri, Desha County, Arkansas, Douglas County, Missouri, Drew County, Arkansas, Dunklin County, Missouri, Faulkner County, Arkansas, Franklin County, Arkansas, Franklin County, Missouri, Fulton County, Arkansas, Garland County, Arkansas, Gasconade County, Missouri, Gentry County, Missouri, Grant County, Arkansas, Greene County, Arkansas, Greene County, Missouri, Grundy County, Missouri, Harrison County, Missouri, Hempstead County, Arkansas, Henry County, Missouri, Hickory County, Missouri, Holt County, Missouri, Hot Spring County, Arkansas, Howard County, Arkansas, Howard County, Missouri, Howell County, Missouri, Independence County, Arkansas, Iron County, Missouri, Izard County, Arkansas, Jackson County, Arkansas, Jackson County, Missouri, Jasper County, Missouri, Jefferson County, Arkansas, Jefferson County, Missouri, Johnson County, Arkansas, Johnson County, Missouri, Knox County, Missouri, Laclede County, Missouri, Lafayette County, Arkansas, Lafayette County, Missouri, Lawrence County, Arkansas, Lawrence County, Missouri, Lee County, Arkansas, Lewis County, Missouri, Lincoln County, Arkansas, Lincoln County, Missouri, Linn County, Missouri, Little River County, Arkansas, Livingston County, Missouri, Logan County, Arkansas, Lonoke County, Arkansas, Macon County, Missouri, Madison County, Arkansas, Madison County, Missouri, Maries County, Missouri, Marion County, Arkansas, Marion County, Missouri, Mcdonald County, Missouri, Mercer County, Missouri, Miller County, Arkansas, Miller County, Missouri, Mississippi County, Arkansas, Mississippi County, Missouri, Moniteau County, Missouri, Monroe County, Arkansas, Monroe County, Missouri, Montgomery County, Arkansas, Montgomery County, Missouri, Morgan County, Missouri, Nevada County, Arkansas, New Madrid County, Missouri, Newton County, Arkansas, Newton County, Missouri, Nodaway County, Missouri, Oregon County, Missouri, Osage County, Missouri, Ouachita County, Arkansas, Ozark County, Missouri, Pemiscot County, Missouri, Perry County, Arkansas, Perry County, Missouri, Pettis County, Missouri, Phelps County, Missouri, Phillips County, Arkansas, Pike County, Arkansas, Pike County, Missouri, Platte County, Missouri, Poinsett County, Arkansas, Polk County, Arkansas, Polk County, Missouri, Pope County, Arkansas, Prairie County, Arkansas, Pulaski County, Arkansas, Pulaski County, Missouri, Putnam County, Missouri, Ralls County, Missouri, Randolph County, Arkansas, Randolph County, Missouri, Ray County, Missouri, Reynolds County, Missouri, Ripley County, Missouri, Saint Charles County, Missouri, Saint Clair County, Missouri, Saint Francis County, Arkansas, Saint Francois County, Missouri, Saint Louis City County, Missouri, Saint Louis County, Missouri, Sainte Genevieve County, Missouri, Saline County, Arkansas, Saline County, Missouri, Schuyler County, Missouri, Scotland County, Missouri, Scott County, Arkansas, Scott County, Missouri, Searcy County, Arkansas, Sebastian County, Arkansas, Sevier County, Arkansas, Shannon County, Missouri, Sharp County, Arkansas, Shelby County, Missouri, Stoddard County, Missouri, Stone County, Arkansas, Stone County, Missouri, Sullivan County, Missouri, Taney County, Missouri, Texas County, Missouri, Union County, Arkansas, Van Buren County, Arkansas, Vernon County, Missouri, Warren County, Missouri, Washington County, Arkansas, Washington County, Missouri, Wayne County, Missouri, Webster County, Missouri, White County, Arkansas, Woodruff County, Arkansas, Worth County, Missouri, Wright County, Missouri, Yell County, Arkansas

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