UnitedHealthcare Medicare Silver (Regional PPO C-SNP)

Plan Basics

Contract Year	2021
Medicare Type	Medicare Advantage Plan (Part C)
CMS Plan ID	R2604-002-000
Plan Organization	UnitedHealthcare
Plan Type	Regional PPO
Plan Name	UnitedHealthcare Medicare Silver (Regional PPO C-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	Chronic or Disabling Condition
Conditions Covered	Cardiovascular Disorders
Overall Star Rating	3.5

Plan Cost Sharing

Premium	$9.70
Total Premium (Includes Part B)	$145.20
Monthly Part C Premium	$0.00
Monthly Part D Basic Premium	$9.70
Monthly Part D Supplemental Premium	$0.00
Monthly Part D Total Premium	$9.70
Monthly Part D Premium Full Assistance	$0.00
Monthly Part D Premium 75% Assistance	$2.40
Monthly Part D Premium 50% Assistance	$4.80
Monthly Part D Premium 25% Assistance	$7.30
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	0-20% coinsurance
Diagnostic tests and procedures	-	Out-of-Network	Yes	No	20% coinsurance
Lab services	-	Out-of-Network	Yes	No	$0 copay
Outpatient x-rays	-	Out-of-Network	Yes	No	20% coinsurance

Doctor Visits

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
Primary	-	Out-of-Network	-	-	$0 copay
Specialist	-	Out-of-Network	Yes	No	$0 copay

Emergency Care/Urgent Care

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
Emergency	-	-	-	-	$90 copay per visit (always covered)
Urgent care	-	-	-	-	$65 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	$0 copay
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	$0 copay

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
	-	-	-	-	$7,550 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	-	20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	-	Out-of-Network	Yes	-	40% 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	$1,400 per stay
Outpatient group therapy visit	-	Out-of-Network	Yes	No	20% coinsurance
Outpatient group therapy visit with a psychiatrist	-	Out-of-Network	Yes	No	20% coinsurance
Outpatient individual therapy visit	-	Out-of-Network	Yes	No	20% coinsurance
Outpatient individual therapy visit with a psychiatrist	-	Out-of-Network	Yes	No	20% 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	0-20% coinsurance 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	$0 copay
Physical therapy and speech and language therapy visit	-	Out-of-Network	Yes	No	$0 copay

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	$0 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

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UnitedHealthcare Medicare Silver (Regional PPO C-SNP) - 2021

UnitedHealthcare Medicare Silver (Regional PPO C-SNP) - UnitedHealthcare - Regional PPO