Erickson Advantage Signature with Drugs (HMO-POS)

UnitedHealthcare
Erickson Advantage Signature with Drugs (HMO-POS) H5652-001 Plan Details
5 out of 5 stars

Erickson Advantage Signature with Drugs (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare.
Plan ID: H5652-001.

$199.00
Monthly Premium

Erickson Advantage Signature with Drugs (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare.
Plan ID: H5652-001.

UnitedHealthcare
Erickson Advantage Signature with Drugs (HMO-POS) H5652-001 Plan Details
5 out of 5 stars

Erickson Advantage Signature with Drugs (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare.
Plan ID: H5652-001.

$199.00
Monthly Premium

Colorado Counties Served

Florida Counties Served

Kansas Counties Served

Maryland Counties Served

Massachusetts Counties Served

Michigan Counties Served

New Jersey Counties Served

North Carolina Counties Served

Pennsylvania Counties Served

Texas Counties Served

Virginia Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $2600
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
POS (Out-of-Network):

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 30%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0.00
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
POS (Out-of-Network):

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 30%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0.00
Your plan covers an unlimited number of days for an inpatient stay.
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 30%
Urgent Care
Copayment for Urgent Care $30.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0.00
Emergency Room Visit
Copayment for Emergency Care $75.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $0.00
Copayment for Worldwide Emergency Transportation $0.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $170.00

Air Ambulance:
Copayment for Air Ambulance Services $170.00

Section B - General 10a Note - NOTE ON AUTHORIZATION: Authorization is required for Non-emergency Medicare-covered ambulance ground and air transportation. Emergency Ambulance does not require authorization.
Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required
POS (Out-of-Network):

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $170.00
Copayment for Medicare Covered Ambulance Services - Air $170.00

Health Care Services and Medical Supplies

Erickson Advantage Signature with Drugs (HMO-POS) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $0.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Chiropractic Services 50%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Diabetic Supplies and Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Diabetic Supplies and Services 30%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Durable Medical Equipment 30%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $50.00
Copayment for Medicare-covered Therapeutic Radiological Services $30.00
Copayment for Medicare-covered X-Ray Services $15.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
POS (Out-of-Network):

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30%
Copayment for Medicare Covered Lab Services $0.00
Coinsurance for Medicare Covered Diagnostic Radiological Services 30%
Coinsurance for Medicare Covered Therapeutic Radiological Services 30%
Copayment for Medicare Covered Outpatient X-Ray Services $20.00
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Home Health 30%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 30%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00 to $30.00
Copayment for Medicare-covered Group Sessions $0.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $50.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per day $50.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $50.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
POS (Out-of-Network):

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 30%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Individual or Group Sessions 30%
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Copayment for Routine Foot Care $0.00
  • Maximum 6 visits every year
Prior Authorization Required for Podiatry Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Podiatry Services 30% Coinsurance for Non-Medicare Covered Podiatry Services 30%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 30%

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 3 visits every year
Copayment for Fluoride Treatment $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Coinsurance for Medicare-covered Benefits 20%
Coinsurance for Non-routine Services 50%
Copayment for Diagnostic Services $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Restorative Services 0% to 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Periodontics 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Extractions 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 0% to 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined
Prior Authorization Required for Comprehensive Dental
Prior authorization required
POS (Out-of-Network):

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 30%
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $0.00
Coinsurance for Non-Medicare Covered Comprehensive Dental 0% to 50%

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year
Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair every year
Maximum Plan Benefit of $100.00 every year for all Non-Medicare covered eyewear
Prior authorization required
POS (Out-of-Network):

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 30%
Copayment for Medicare Covered Eyewear $0.00
Non-Medicare Covered Vision Services:
Coinsurance for Non-Medicare Covered Eye Exams 30%
Copayment for Non-Medicare Covered Eyewear $0.00

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $375.00 to $1425.00
  • Maximum 2 Hearing Aids every year
Prior Authorization Required for Hearing Aids
Section B - General 18b Note - NOTE ON COST SHARING: Copays will range from a minimum copay of $375 to a maximum of $1,425 based on features and style. NOTE ON COMBINED COVERAGE FOR HEARING AID BENEFIT: Member may purchase a total of two hearing aids every year.
Prior authorization required
POS (Out-of-Network):

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 30%
Non-Medicare Covered Hearing Services:
Coinsurance for Non-Medicare Covered Hearing Exams 30%
Copayment for Non-Medicare Covered Hearing Aids $375.00

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    POS (Out-of-Network):

    Medicare-covered Zero Dollar Preventive Services:
    Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 30%