UHC Sharp Medicare Advantage ValueRx CA-12P (HMO-POS)

In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0 to $35
Prior Authorization Required for Doctor Specialty Visit
Referral 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.

In-Network:

Acute Hospital Services:
$375 per day for days 1 to 7
$0 per day for days 8 to 90
Prior Authorization Required for Acute Hospital Services
Referral 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 $65

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 $150
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $200

Air Ambulance:
Copayment for Air Ambulance Services $200
Prior Authorization Required for Air Ambulance

In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0
Copayment for Routine Care $0

• Maximum 12 Routine Care every year

Prior Authorization Required for Chiropractic Services
Referral 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 $0
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Referral Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $320
Copayment for Medicare-covered Therapeutic Radiological Services $60
Copayment for Medicare-covered X-Ray Services $10

In-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Referral Required for Home Health Services

In-Network:

Psychiatric Hospital Services:
$375 per day for days 1 to 6
$0 per day for days 7 to 90
Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services
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 $375
Prior Authorization Required for Outpatient Hospital Services
Referral 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 $375
Prior Authorization Required for Outpatient Observation Services
Referral 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 $325
Prior Authorization Required for Ambulatory Surgical Center Services
Referral 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.

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
Referral 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.

In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $35
Prior Authorization Required for Podiatry Services
Referral Required for Podiatry Services

In-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$221 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Referral Required for Skilled Nursing Facility Services

$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

In-Network

Routine Eye Exam: $0 copay 1 exam per year
Routine Eyewear: $0 copay for standard prescription lenses
$200 allowance every 2 years for 1 pair of lenses/frames or contacts.

In-Network

Routine Hearing Exam: $0 copay 1 exam per year
Routine Hearing Aids: $1,000 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.

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