AARP Medicare Advantage from UHC HI-5 (PPO)

Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $40

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0 to $50
Prior Authorization Required for Doctor Specialty Visit
Note: The lower cost share applies to Medicare covered telehealth and Medicare covered remote monitoring. The higher cost share applies to all other Medicare covered services.

Out-of-Network:

Acute Hospital Services:
Coinsurance for Acute Hospital Services per Stay 40%
Note: All inpatient substance abuse and mental health care (including both care received in an acute care facility and a Medicare-certified psychiatric facility) are included in category 1b.

Urgent Care:
Copayment for Urgent Care $0 to $50

Note: The lower cost share applies to Medicare covered telehealth. The higher cost share applies to all other Medicare covered services.

Emergency Care:
Copayment for Emergency Care $130
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $350
Copayment for Medicare Covered Ambulance Services - Air $350

Out-of-Network:

Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $90
In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $10
Copayment for Routine Care $10

• Maximum 12 Routine Care every year

Prior Authorization Required for Chiropractic Services

Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 50%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 50%

In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 30%
Prior Authorization Required for Durable Medical Equipment

Out-of-Network:

Diagnostic Procedures/Tests Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40%
Copayment for Medicare Covered Lab Services $0
Coinsurance for Medicare Covered Diagnostic Radiological Services 40%
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Copayment for Medicare Covered Outpatient X-Ray Services $50

Out-of-Network:

Home Health Services:
Coinsurance for Medicare Covered Home Health 50%

Out-of-Network:

Psychiatric Hospital Services:
Coinsurance for Psychiatric Hospital per Stay 40%
Benefit Details - General Note - NOTE ON INPATIENT SUBSTANCE ABUSE: All inpatient substance abuse and mental health care (including both care received in an acute care facility and a Medicare-certified psychiatric facility) are included in category 1b.

Out-of-Network:

Mental Health Services:
Copayment for Medicare Covered Individual Sessions $40
Copayment for Medicare Covered Group Sessions $30

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $550
Prior Authorization Required for Outpatient Hospital Services
Note: The lower cost share applies to outpatient diagnostic colonoscopies. The higher cost share applies to all other outpatient procedures.Note: Benefit category includes both the facility and professional component.

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per day $550
Prior Authorization Required for Outpatient Observation Services
Benefit Details - General 9a2 Note - NOTE ON OBSERVATION SERVICES: Benefit category includes both the facility and professional component.

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $500
Prior Authorization Required for Ambulatory Surgical Center Services
Benefit Details - General 9b Note - NOTE ON ASC SERVICES: Benefit category 9b includes both the facility and professional component.Benefit Details - General 9b Note - NOTE ON COST SHARING RANGE FOR ASC Services: The lower cost share applies to outpatient diagnostic colonoscopies. The higher cost share applies to all other outpatient procedures.

Out-of-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare Covered Individual Sessions $40
Copayment for Medicare Covered Group Sessions $30
Note: The lower cost share applies to Medicare covered telehealth for individual sessions. The higher cost share applies to all other Medicare covered services.
In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0 to $25
Copayment for Medicare-covered Group Sessions $15
Prior Authorization Required for Outpatient Substance Abuse Services
Note: The lower cost share applies to Medicare covered telehealth for individual sessions. The higher cost share applies to all other Medicare covered services.

In-Network
Over-The-Counter (OTC) Items:
$25 Credit per quarter for OTC products like vitamins, pain relievers, first aid supplies and more in store or online. A minimum of $20 before applicable tax applies to online order. Shop at thousands of participating stores, including Walmart, Walgreens and Dollar general, or at neighborhood stores near you.$25 Credit per quarter for OTC products like vitamins, pain relievers, first aid supplies and more in store or online. A minimum of $20 before applicable tax applies to online order. Shop at thousands of participating stores, including Walmart, Walgreens and Dollar general, or at neighborhood stores near you.

Out-of-Network

Over-The-Counter (OTC) Items:
90% coinsurance up to credit amount

Out-of-Network:

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $90
In-Network
$45 copay 6 visits per year

Out-of-Network:

Skilled Nursing Facility Services:
$250 per day for days 1 to 100

Out-of-Network:

Preventive Dental Services:
Coinsurance for Medicare Covered Preventive Dental 40%

Out-of-Network:

Eye Exams Services:
Copayment for Medicare Covered Eye Exams $90
Coinsurance for Medicare Covered Eyewear 40%

Out-of-Network:

Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $90

Out-of-Network:

Medicare-covered Preventive Services:
Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 40%