UHC Complete Care Support GA-9 (PPO C-SNP)

Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $20

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.

In-Network:

Acute Hospital Services:
$590 per day for days 1 to 4
$0 per day for days 5 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 $80
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
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0

Out-of-Network:

Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 50%

In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $55
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 $285
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $25

In-Network:

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

Out-of-Network:

Psychiatric Hospital Services:
$715 per day for days 1 to 12
$0 per day for days 13 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 $590
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 $590
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 $540
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.

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:

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
Over-The-Counter (OTC) Items:
$80 credit per month for OTC products like first aid supplies, pain relievers and more, plus healthy food like fruits, vegetables and meat for qualifying members. Shop at thousands of participating stores, including Walmart, Walgreens and Dollar General, or at neighborhood stores near you.

Out-of-Network:

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $80
In-Network
$0 copay 6 visits per year

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

Out-of-Network:

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

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.

Out-of-Network: Routine Eye Exam:$80 copayRoutine Eyewear: 90% coinsurance up to allowance

Out-of-Network:

Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $80

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