UHC Dual Choice DC-S001 (PPO D-SNP)

UnitedHealthcare
UHC Dual Choice DC-S001 (PPO D-SNP) H2406-053 Plan Details
4 out of 5 stars

UHC Dual Choice DC-S001 (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H2406-053

Have Medicare questions?

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

$0.00
Monthly Premium

UHC Dual Choice DC-S001 (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H2406-053

Have Medicare questions?

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

UnitedHealthcare
UHC Dual Choice DC-S001 (PPO D-SNP) H2406-053 Plan Details
4 out of 5 stars

UHC Dual Choice DC-S001 (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H2406-053

Have Medicare questions?

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

$0.00
Monthly Premium

District of Columbia Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $8850
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
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
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:
Copayment for Acute Hospital Services per Stay $0.00
Urgent Care
Copayment for Urgent Care $0.00

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 $0.00
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 $0.00

Air Ambulance:
Copayment for Air Ambulance Services $0.00

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:
Coinsurance for Medicare Covered Ambulance Services - Ground 20%
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

UHC Dual Choice DC-S001 (PPO D-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 $0.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 30%
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 30%
Durable Medical Eqipment (DME)
In-Network:
Copayment for Medicare-covered Durable Medical Equipment $0.00
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
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
Copayment for Medicare-covered Therapeutic Radiological Services $0.00
Copayment for Medicare-covered X-Ray Services $0.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
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%
Coinsurance for Medicare Covered Outpatient X-Ray Services 30%
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 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:
Copayment for Psychiatric Hospital Services per Stay $0.00
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
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
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
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 $0.00
Copayment for Medicare-covered Group Sessions $0.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Individual or Group Sessions 30%
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 $119.00 every month
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 $119.00
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Copayment for Routine Foot Care $0.00
  • Maximum 4 visits every year
Prior Authorization Required for Podiatry Services
Prior authorization required
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 20
$0.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
Copayment for Skilled Nursing Facility Services per Stay $0.00

Dental Benefits

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

Coverage Cost
Dental Care
In-Network:

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 30%

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
Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Prior authorization required
Out-of-Network:

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 30%
Coinsurance for Medicare Covered Eyewear 30%

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
Prior authorization required
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%

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

    Prescription Drug Costs and Coverage

    The UHC Dual Choice DC-S001 (PPO D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $0 per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $0
    Preferred Generic
    • Standard retail $0.00
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Generic
    • Standard retail $0.00
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Preferred Brand
    • Standard retail $0.00
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Non-Preferred Drug
    • Standard retail $0.00
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Specialty Tier
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00
    Annual Drug Deductible $0
    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
    Non-Preferred Drug
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Specialty Tier
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Annual Drug Deductible $0
    Preferred Generic
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00
    Generic
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00
    Preferred Brand
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00
    Non-Preferred Drug
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00
    Specialty Tier
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A