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UHC Complete Care TX-0029 (Regional PPO C-SNP)

UnitedHealthcare
UHC Complete Care TX-0029 (Regional PPO C-SNP) R6801-009 Plan Details
4 out of 5 stars

UHC Complete Care TX-0029 (Regional PPO C-SNP) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: R6801-009

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$22.00
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UHC Complete Care TX-0029 (Regional PPO C-SNP) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: R6801-009

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Get Medicare Help
UnitedHealthcare
UHC Complete Care TX-0029 (Regional PPO C-SNP) R6801-009 Plan Details
4 out of 5 stars

UHC Complete Care TX-0029 (Regional PPO C-SNP) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: R6801-009

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Get Medicare Help
$22.00
Monthly Premium

Texas Counties Served

Kaufman Zavala Mclennan Shackelford Parker Jones Armstrong Real Nueces Galveston Kendall Midland Hidalgo Ellis Coleman Dona Ana Medina Kleberg Johnson Tarrant Frio Ector Callahan Rockwall Potter Randall Navarro Collin Cameron Carson Willacy Comal Kerr Jim Wells Wood Dimmit Martin Howard Caldwell Taylor Bexar Hood Wise Dallas Denton San Patricio Grayson Bandera Maverick Aransas Deaf Smith Wilson Jefferson Montague Edwards Bee El Paso Cooke Hill Lubbock Guadalupe Burnet Blanco Travis Llano Williamson Lampasas San Saba Gillespie Hays Walker Orange Grimes Polk Waller Hardin Jasper Liberty Chambers Montgomery Tyler Wharton Brazoria Washington Matagorda Austin Brazos Fort Bend San Jacinto Bell Harris Hudspeth Hunt Van Zandt Fannin Erath Live Oak Hall Gaines Garza Hockley Sherman Lynn Foard Calhoun Cochran Andrews Young Mitchell Dickens Swisher Coke Bastrop Upton Castro Terry Irion Hansford Donley Crosby Knox Bailey Oldham Victoria Hardeman Stephens Motley Yoakum Reagan Fisher Sterling Baylor Lee Dallam Haskell Jackson Crane Borden Concho Floyd Hale Hutchinson Briscoe Stonewall Dawson King Glasscock Lamb Hartley Tom Green Moore Kent Runnels Roberts Gonzales Uvalde Karnes De Witt Sutton Pecos Freestone Jack Kenedy Limestone Goliad Jeff Davis La Salle Hopkins Camp Rusk Gregg Panola Brooks Henderson Falls Anderson Houston Coryell Marion Upshur Titus Burleson Mason Kimble Zapata Somervell Madison Winkler Leon Presidio Hamilton Reeves Loving Throckmorton Brewster Mills Refugio Schleicher Mcculloch Robertson Rains Milam Lavaca Clay Kinney Jim Hogg Morris San Augustine Harrison Delta Palo Pinto Webb Cass Red River Archer Shelby Fayette Colorado Mcmullen Duval Bosque Nacogdoches Menard Culberson Cherokee Trinity Bowie Smith Lamar Franklin Gray Nolan Brown Starr Val Verde Ward Comanche Angelina Wheeler Scurry Crockett Newton Cottle Wilbarger Ochiltree Sabine Hemphill Eastland Terrell Wichita Collingsworth Childress Lipscomb Parmer

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $295
Out of Pocket Max In-Network: $6700
Out-of-Network: N/A
Initial Coverage Limit $5030
Catastrophic Coverage Limit $8,000
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00 to $5.00
Out-of-Network:

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $20.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0.00 to $45.00
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $45.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$260.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
$260.00 per day for days 1 to 7
$0.00 per day for days 8 to 999
Urgent Care
Copayment for Urgent Care $0.00 to $40.00

Benefit Details - General 4b Note - NOTE ON COST SHARING RANGE FOR URGENTLY NEEDED SERVICES: $0 copayment applies to Medicare covered telehealth. The higher cost share applies to all other Medicare covered services.

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

Ground Ambulance:
Copayment for Ground Ambulance Services $290.00

Air Ambulance:
Copayment for Air Ambulance Services $290.00

Benefit Details - 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
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $290.00
Copayment for Medicare Covered Ambulance Services - Air $290.00

Health Care Services and Medical Supplies

UHC Complete Care TX-0029 (Regional PPO C-SNP) 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 $15.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Chiropractic Services $15.00
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Diabetic Supplies and Services 50%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment 50%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $50.00
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 $250.00
Copayment for Medicare-covered Therapeutic Radiological Services $60.00
Copayment for Medicare-covered X-Ray Services $25.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $50.00
Copayment for Medicare Covered Lab Services $0.00
Copayment for Medicare Covered Diagnostic Radiological Services $0.00 to $250.00
Copayment for Medicare Covered Therapeutic Radiological Services $60.00
Copayment for Medicare Covered Outpatient X-Ray Services $25.00
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Home Health 50%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$260.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
$260.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00 to $25.00
Copayment for Medicare-covered Group Sessions $15.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Individual Sessions $15.00 to $25.00
Copayment for Medicare Covered Group Sessions $15.00 to $25.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $260.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per day $260.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $260.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Outpatient Hospital and ASC Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $260.00
Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00 to $260.00
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00 to $25.00
Copayment for Medicare-covered Group Sessions $15.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Individual or Group Sessions $15.00 to $25.00
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 $40.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Out-of-Network:

Over-The-Counter (OTC) Items:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $40.00
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
Out-of-Network:
Copayment for Medicare Covered Podiatry Services $0.00 Copayment for Non-Medicare Covered Podiatry Services $0.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 to 100

Dental Benefits

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

Coverage Cost
Dental Care
In-Network:

Comprehensive Dental:
Coinsurance for Medicare-covered Benefits 20%
Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 20%

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
Prior authorization required
Out-of-Network:

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $0.00
Copayment for Medicare Covered Eyewear $0.00
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $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 $99.00 to $1249.00
  • Maximum 2 Hearing Aids every year
Prior Authorization Required for Hearing Aids
Prior authorization required
Out-of-Network:

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $45.00
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $45.00
Copayment for Non-Medicare Covered Hearing Aids $99.00 to $1249.00

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
    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 UHC Complete Care TX-0029 (Regional PPO C-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $295 (excludes Tiers 1, 2 and 3) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $295 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Standard retail $4.00
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Generic
    • Standard retail $12.00
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Preferred Brand
    • Standard retail $47.00
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Annual Drug Deductible $295 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Generic
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Preferred Brand
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Annual Drug Deductible $295 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Standard retail $12.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $12.00
    Generic
    • Standard retail $36.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $36.00
    Preferred Brand
    • Standard retail $141.00
    • Preferred cost-share mail order $131.00
    • Standard mail order $141.00
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