United Healthcare Medicare Advantage Assure (PPO) H0271:008-0 Plan Details

In this article...
  • Learn more about United Healthcare Medicare Advantage Assure (PPO) H0271:008-0, including how much you can expect to pay for coinsurance, deductibles, premiums and copays for various services covered by the plan.

Arizona Counties Served

Yavapai County

Santa Cruz County

Graham County

Plan Details and Plan Costs

UnitedHealthcare Medicare Advantage Assure (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered in Arizona by UnitedHealthcare. The plan ID is H0271:008-0.

  • Monthly Premium: $27.20
  • Plan Deductible: $0.00
  • Out of Pocket Spending Max: $7550

Primary Care Doctor Visit

In Network: $0.00 Copayment

Out of Network: 30% Coinsurance

Specialist Doctor Visit

In Network:

  • $0 Copayment for Physician Specialist Office Visit
  • Prior Authorization Required for Doctor Specialty Visit

Out of Network:

  • 30% Coinsurance

Inpatient Hospital Care

In Network:

  • Copayment for Acute Hospital Services per Stay: $1400.00
  • Your plan covers an unlimited number of days for an inpatient stay
  • Prior Authorization Required for Acute Hospital Services

Out of Network:

  • 30% Coinsurance

Urgent Care

Copayment for Urgent Care: $65.00

Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0.00

Emergency Room (ER) Visits

In Network:

  • 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: 20% Coinsurance
  • Air Ambulance: 20% Coinsurance

Section B - 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

Out of Network:

  • Ground Ambulance: 20% Coinsurance
  • Air Ambulance: 20% Coinsurance

Additional Covered Health Care Services and Medical Supplies

UnitedHealthcare Medicare Advantage Assure (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Home Health Care

In Network: $0.00 Copay

  • Prior Authorization Required for Home Health Services

Out of Network: 30% Coinsurance 

Skilled Nursing Facility (SNF) Care

In Network:

  • $0.00 per day for days 1 to 20
  • $170.50 per day for days 21 to 100
  • Prior Authorization Required for Skilled Nursing Facility Services

Out of Network:

  • 30% Coinsurance 

Medical Diagnostic Tests, Labs and Radiology Services

Outpatient Diagnostic Procedures, Tests and Lab Services:

  • Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20%
  • Copayment for Medicare-covered Lab Services $0.00
  • Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Service

Outpatient Diagnostic and Therapeutic Radiology Services:

  • Coinsurance for Medicare-covered Diagnostic Radiological Services 0% to 20%
  • Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
  • Coinsurance for Medicare-covered X-Ray Services 20%
  • Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services

Diabetes Supplies, Training, Nutrition Therapy and Monitoring

In-Network:

  • Copayment for Medicare-covered Diabetic Supplies $0.00
  • Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
  • Prior Authorization Required for Diabetic Supplies and Services
    Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)

Durable Medical Equipment (DME)

In Network:

  • Coinsurance for Medicare-covered Durable Medical Equipment: 20%
  • Prior Authorization Required for Durable Medical Equipment

Out of Network:

  • Coinsurance for Medicare Covered Durable Medical Equipment: 30%

Chiropractic Services

In Network:

  • Copayment for Medicare-covered Chiropractic Services: $0.00
  • Copayment for Routine Care: $0.00
  • Maximum 20 Routine Care every year

Out of Network:

  • Coinsurance for Medicare Covered Chiropractic Services: 30%
  • Coinsurance for Non-Medicare Covered Chiropractic Services: 30%

Mental Health Inpatient Care

In Network:

  • Copayment for Psychiatric Hospital Services per Stay: $1400.00
  • Prior Authorization Required for Psychiatric Hospital Services

Out of Network:

  • Coinsurance for Psychiatric Hospital Services per Stay: 30%

Mental Health Outpatient Care

In Network:

  • Coinsurance for Medicare-covered Individual Sessions: 20%
  • Coinsurance for Medicare-covered Group Sessions: 20%
  • Prior Authorization Required for Outpatient Mental Health Services

Out of Network:

  • Coinsurance for Medicare Covered Individual Sessions: 30%
  • Coinsurance for Medicare Covered Group Sessions: 30%

Outpatient Substance Abuse Care

In Network:

  • Coinsurance for Medicare-covered Individual Sessions: 20%
  • Coinsurance for Medicare-covered Group Sessions: 20%
  • Prior Authorization Required for Outpatient Substance Abuse Services

Podiatry Services

In Network:

  • Copayment for Medicare-Covered Podiatry Services: $0.00
  • Copayment for Routine Foot Care: $0.00
  • Maximum 4 visits every year

Transportation Services

Copayment for Transportation Services: $0.00

  • Plan allows 24 one way trips to a Plan-approved location every year
  • Section B - General 10b Note - NOTE ON MODE OF TRANSPORTATION: Van refers to multi-load or wheelchair van only. Car or livery service may be substituted for van transportation.

Over-the-Counter (OTC) Items

Copayment for Over-The-Counter (OTC) Items: $0.00

  • Maximum Plan Benefit of $250.00 every three months
  • Nicotine Replacement Therapy (NRT) offered as a Part C OTC benefit

Dental Benefits

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

Preventive Dental Care

Oral Exams:

  • $0 Copayment for Oral Exams
  • Maximum 2 visits every year

Teeth Cleaning:

  • Copayment for Prophylaxis (Cleaning): $0.00
  • Maximum 3 visits every year

Fluoride Treatment:

  • Copayment for Fluoride Treatment: $0.00
  • Maximum 2 visits every year

Dental X-Rays:

  • Copayment for Dental X-Rays: $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Maximum Plan Benefit:

  • Maximum Plan Benefit of $1500.00 every year for in and out of network services combined, for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental Care

Medicare-Covered Benefits:

  • Coinsurance for Medicare-covered Benefits: 20%

Non-Routine services:

  • Copayment for Non-routine Services: $0.00

Diagnostic Services:

  • Copayment for Diagnostic Services: $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Restorative Services:

  • Copayment for Restorative Services: $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Endodontics:

  • Copayment for Endodontics: $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Periodontics:

  • Copayment for Periodontics: $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Teeth Extractions:

  • Copayment for Extractions: $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Prosthodontics, Oral/Maxillofacial Surgery, Other Services:

  • Copayment: $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Maximum Plan Benefit:

  • Maximum Plan Benefit of $1500.00 every year for in and out of network services combined, for Preventive and Non-Medicare Covered Comprehensive combined
  • Prior Authorization Required for Comprehensive Dental

Vision Benefits

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

Eye Exams

Medicare-Covered Benefits:

  • Copayment for Medicare Covered Benefits: $0.00

Routine Eye Exams:

  • Copayment for Routine Eye Exams: $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear

Medicare-Covered Benefits:

  • Copayment for Medicare-Covered Benefits: $0.00

Contact Lenses:

  • Copayment for Contact Lenses: $0.00

Eyeglasses (lenses and frames):

  • Copayment for Eyeglasses (lenses and frames): $0.00
  • Maximum 1 Pair every two years

Maximum Plan Benefit:

  • Maximum Plan Benefit of $200.00 every two years for all Non-Medicare covered eyewear for in and out of network services combined

Hearing Benefits

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

Hearing Exams

Medicare-Covered Benefits:

  • Copayment for Medicare Covered Benefits: $0.00

Routine Hearing Exams:

  • Copayment for Routine Hearing Exams: $0.00
  • Maximum 1 visit every year
  • Prior Authorization Required for Hearing Exams

Hearing Aids

Maximum Plan Allowance of $2000.00 every two years both ears combined for in and out of network services combined

  • Prior Authorization Required for Hearing Aids

Preventive Services and Health/Wellness Education Programs

The following preventive services and wellness education programs are covered from in-network providers with $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:

  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation

Prescription Drug Costs and Coverage

The UnitedHealthcare Medicare Advantage Assure (PPO) plan offers the following prescription drug coverage in Arizona, with an annual drug deductible of $445 per year.

Preferred Generic Drugs

  • Preferred Retail Cost Sharing (30 Day Supply) 25%
  • Preferred Mail Order Cost Sharing (90 Day Supply) 25%
  • Standard Retail Cost Sharing (30 Day Supply) 25%
  • Standard Mail Order Cost Sharing (90 Day Supply) 25%

Generic Drugs

  • Preferred Retail Cost Sharing (30 Day Supply) 25%
  • Preferred Mail Order Cost Sharing (90 Day Supply) 25%
  • Standard Retail Cost Sharing (30 Day Supply) 25%
  • Standard Mail Order Cost Sharing (90 Day Supply) 25%

Preferred Brand Name Drugs

  • Preferred Retail Cost Sharing (30 Day Supply) 25%
  • Preferred Mail Order Cost Sharing (90 Day Supply) 25%
  • Standard Retail Cost Sharing (30 Day Supply) 25%
  • Standard Mail Order Cost Sharing (90 Day Supply) 25%

Non-Preferred Drugs

  • Preferred Retail Cost Sharing (30 Day Supply) 25%
  • Preferred Mail Order Cost Sharing (90 Day Supply) 25%
  • Standard Retail Cost Sharing (30 Day Supply) 25%
  • Standard Mail Order Cost Sharing (90 Day Supply) 25%

Specialty Tier Drugs

  • Preferred Retail Cost Sharing (30 Day Supply) 25%
  • Standard Retail Cost Sharing (30 Day Supply) 25%
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