UHC Dual Complete LA-Q1 (PPO D-SNP)

Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $0
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:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0
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.

Out-of-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0
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

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 $0
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 $0
Copayment for Medicare Covered Ambulance Services - Air $0

In-Network:

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

Out-of-Network:

Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $0

Out-of-Network:

Diabetic Supplies and Services:
Copayment for Medicare Covered Diabetic Supplies $0
Copayment for Medicare Covered Diabetic Therapeutic Shoes or Inserts $0

In-Network:

Durable Medical Equipment:
Copayment for Medicare-covered Durable Medical Equipment $0
Prior Authorization Required for Durable Medical Equipment

Out-of-Network:

Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0
Copayment for Medicare Covered Lab Services $0
Copayment for Medicare Covered Diagnostic Radiological Services $0
Copayment for Medicare Covered Therapeutic Radiological Services $0
Copayment for Medicare Covered Outpatient X-Ray Services $0

In-Network:

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

In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0
Prior Authorization 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.

Out-of-Network:

Mental Health Services:
Copayment for Medicare Covered Individual Sessions $0
Copayment for Medicare Covered Group Sessions $0

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0
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 $0
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
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
Copayment for Medicare-covered Group Sessions $0
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 $0
Copayment for Medicare Covered Group Sessions $0
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:

Over-The-Counter (OTC) Items Services:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0

In-Network
$0 copay 6 visits per year
Out-of-Network:

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $0

In-Network:

Skilled Nursing Facility Services:
Copayment for Skilled Nursing Facility Services per Stay $0
Prior Authorization Required for Skilled Nursing Facility Services

$1,500 allowance per year toward covered preventive and comprehensive services.
$0 copay for covered preventive services such as oral exams, routine cleanings, X-rays and fluoride
$0 copay for all covered comprehensive services, such as fillings, crowns, root canals, extractions, bridges and dentures
You will have access to one of Medicare Advantage's largest dental networks, or you can choose any dentist.

In-Network

Routine Eye Exam: $0 copay 1 exam per year
Routine Eyewear: $0 copay for standard prescription lenses
$250 allowance every year for 1 pair of lenses/frames or contacts.

Out-of-Network: Routine Eye Exam:30% of the costRoutine Eyewear: 90% coinsurance up to allowance

In-Network

Routine Hearing Exam: $0 copay 1 exam per year
Routine Hearing Aids: $2,200 allowance up to 2 hearing aids every 2 years
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.
Out-of-Network Routine Hearing Exam:30% of the cost
Routine Hearing Aids:90% coinsurance up to allowance

Out-of-Network:

Medicare-covered Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0