UCare Essentials Rx (HMO-POS)
UCare Essentials Rx (HMO-POS) H2459-023 Plan Details
UCare Essentials Rx (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UCare Minnesota.
Plan ID: H2459-023.
$0.00
Monthly Premium
UCare Essentials Rx (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UCare Minnesota.
Plan ID: H2459-023.
Minnesota Counties Served
Aitkin
Anoka
Becker
Beltrami
Benton
Carlton
Carver
Cass
Chisago
Clay
Clearwater
Cook
Crow Wing
Dakota
Douglas
Grant
Hennepin
Hubbard
Isanti
Itasca
Kanabec
Kittson
Koochiching
Lake
Lake of the Woods
Mahnomen
Marshall
Mille Lacs
Morrison
Norman
Otter Tail
Pennington
Pine
Polk
Ramsey
Red Lake
Roseau
Scott
Sherburne
St. Louis
Stearns
Todd
Wadena
Washington
Wilkin
Wright
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $395 |
| Out of Pocket Max |
In-Network: $-1 Out-of-Network: 7500 |
| Initial Coverage Limit | $0 |
| 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: Copayment for Medicare Covered Primary Care Office Visit $0.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $45.00 POS (Out-of-Network): Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $45.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $400.00 Your plan covers an unlimited number of days for an inpatient stay. Out-of-Network: Coinsurance for Acute Hospital Services per Stay 20% |
| Urgent Care | Copayment for Urgent Care $50.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $100.00 |
| Emergency Room Visit | Copayment for Emergency Care $90.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 Copayment for Worldwide Emergency Transportation $100.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $250.00 Air Ambulance: Copayment for Air Ambulance Services $250.00 POS (Out-of-Network): Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $250.00 Copayment for Medicare Covered Ambulance Services - Air $250.00 |
Health Care Services and Medical Supplies
UCare Essentials Rx (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 $20.00 |
| 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% Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) POS (Out-of-Network): Coinsurance for Medicare Covered Diabetic Supplies and Services 20% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare-covered Diagnostic Procedures/Tests 10% Copayment for Medicare-covered Lab Services $0.00 Maximum out of Pocket $75.00 (Please see Evidence of Coverage) Outpatient Diag/Therapeutic Rad Services: Coinsurance for Medicare-covered Diagnostic Radiological Services 10% Coinsurance for Medicare-covered Therapeutic Radiological Services 10% Coinsurance for Medicare-covered X-Ray Services 10% Maximum out of Pocket $75.00 (Please see Evidence of Coverage) POS (Out-of-Network): Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 20% Copayment for Medicare Covered Lab Services $0.00 Coinsurance for Medicare Covered Diagnostic Radiological Services 20% Coinsurance for Medicare Covered Therapeutic Radiological Services 20% Coinsurance for Medicare Covered Outpatient X-Ray Services 20% |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 POS (Out-of-Network): Coinsurance for Medicare Covered Home Health 20% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $400.00 Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 20% |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 POS (Out-of-Network): Copayment for Medicare Covered Individual Sessions $40.00 Copayment for Medicare Covered Group Sessions $40.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $300.00 Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $300.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $275.00 POS (Out-of-Network): Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 20% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20% |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $35.00 Copayment for Medicare-covered Group Sessions $35.00 POS (Out-of-Network): Coinsurance for Medicare Covered Individual or Group Sessions 20% |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $75.00 every six months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $45.00 POS (Out-of-Network): Copayment for Medicare Covered Podiatry Services $45.00 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $188.00 per day for days 21 to 100 Out-of-Network: Coinsurance for Skilled Nursing Facility Services per Stay 20% |
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
Copayment for Dental X-Rays $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 Copayment for Periodontics $0.00
POS (Out-of-Network): Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 20% Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Preventive Dental $0.00 Copayment for Non-Medicare Covered Comprehensive Dental $0.00 |
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 to $45.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00 Copayment for Eyeglass Lenses $0.00 Copayment for Eyeglass Frames $0.00 Copayment for Upgrades $0.00 Maximum Plan Benefit of $150.00 every year for all Non-Medicare covered eyewear POS (Out-of-Network): Medicare Covered Vision Services: Coinsurance for Medicare Covered Eye Exams 20% Coinsurance for Medicare Covered Eyewear 20% Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eyewear $0.00 Maximum Plan Benefit of $150.00 every year |
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 $45.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $699.00 to $999.00
POS (Out-of-Network): Medicare Covered Hearing Services: Coinsurance for Medicare Covered Hearing Exams 20% |
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:
Yearly "Wellness" visit POS (Out-of-Network): Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
Prescription Drug Costs and Coverage
The UCare Essentials Rx (HMO-POS) plan offers the following prescription drug coverage, with an annual drug deductible of $395 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $395 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $395 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $395 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
