AARP Medicare Advantage Patriot No Rx WV-MA01 (PPO)

Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $0

Out-of-Network:

Doctor Specialty Visit Services:
Copayment for Medicare Covered Physician Specialist Office Visit $55
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.

In-Network:

Acute Hospital Services:
$490 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services
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 $40

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 $115
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 $55
In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Prior Authorization Required for Chiropractic Services

In-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%

In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment

In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $50
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $320
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $30

Out-of-Network:

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

Out-of-Network:

Psychiatric Hospital Services:
$490 per day for days 1 to 5
$0 per day for days 6 to 90
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.

In-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0 to $25
Copayment for Medicare-covered Group Sessions $15

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $490
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 $490
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 $440
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.

Out-of-Network:

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $55
In-Network
$45 copay 6 visits per year

Out-of-Network:

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

$0 copay for covered preventive services such as oral exams, routine cleanings, X-rays and fluoride
You will have access to one of Medicare Advantage's largest dental networks, or you can choose any dentist.

Dental Rider:
Add $54 to your monthly premium.

As a UnitedHealthcare member, you have the option to get dental coverage through the Platinum Dental Rider for an additional monthly fee. You will have access to one of Medicare Advantage's largest dental networks, or you can choose any dentist. Seeing a network dentist may save you money.

$1,500 per year for covered dental services through the Platinum Dental Rider.
$0 copay for covered network preventive services such as oral exams, routine cleanings, X-rays and fluoride
50% coinsurance for all comprehensive dental services, like crowns, fillings, extractions, bridges and dentures

Out-of-Network:

Eye Exams Services:
Copayment for Medicare Covered Eye Exams $55
Coinsurance for Medicare Covered Eyewear 40%

In-Network

Routine Hearing Exam: $0 copay 1 exam per year
Routine Hearing Aids: $700 allowance up to 2 hearing aids per year
Choose from a broad selection of brand-name prescription hearing aids through UnitedHealthcare Hearing. Access to one of the largest national networks with thousands of hearing professionals.
Out-of-Network Routine Hearing Exam:$55 copay
Routine Hearing Aids:90% coinsurance up to allowance

Out-of-Network:

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