UHC Medicare Advantage GA-2 (PPO)

In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0 to $60
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:
Coinsurance for Acute Hospital Services per Stay 50%
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

In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $290

Air Ambulance:
Copayment for Air Ambulance Services $290
Prior Authorization Required for Air Ambulance

Out-of-Network:

Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $100
In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Prior Authorization Required for Chiropractic Services

Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 50%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 50%

Out-of-Network:

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

Out-of-Network:

Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $75
Copayment for Medicare Covered Lab Services $0
Copayment for Medicare Covered Diagnostic Radiological Services $420
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Copayment for Medicare Covered Outpatient X-Ray Services $50

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:
$460 per day for days 1 to 3
$0 per day for days 4 to 90
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.

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 $460
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 $460
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 $410
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.

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:

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.

In-Network
$45 copay 6 visits per year
Out-of-Network:

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $100

Out-of-Network:

Skilled Nursing Facility Services:
$250 per day for days 1 to 100

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
$250 allowance every 2 years for 1 pair of lenses/frames or contacts.

Out-of-Network: Routine Eye Exam:$100 copayRoutine Eyewear: 90% coinsurance up to allowance

In-Network

Routine Hearing Exam: $0 copay 1 exam per year
Routine Hearing Aids: $700 allowance up to 2 hearing aids per year
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:$100 copay
Routine Hearing Aids:90% coinsurance up to allowance

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