UnitedHealthcare Medicare Advantage Choice Plan 2 (PPO)

UnitedHealthcare
UnitedHealthcare Medicare Advantage Choice Plan 2 (PPO) H1659-003 Plan Details
3.5 out of 5 stars

UnitedHealthcare Medicare Advantage Choice Plan 2 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare.
Plan ID: H1659-003.

$0.00
Monthly Premium

UnitedHealthcare Medicare Advantage Choice Plan 2 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare.
Plan ID: H1659-003.

UnitedHealthcare
UnitedHealthcare Medicare Advantage Choice Plan 2 (PPO) H1659-003 Plan Details
3.5 out of 5 stars

UnitedHealthcare Medicare Advantage Choice Plan 2 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare.
Plan ID: H1659-003.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $405
Out of Pocket Max In-Network: $6700
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
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 $50.00
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $70.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$350.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 40%
Urgent Care
Copayment for Urgent Care $40.00

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 $260.00

Air Ambulance:
Copayment for Air Ambulance Services $260.00

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
Prior authorization required
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $260.00
Copayment for Medicare Covered Ambulance Services - Air $260.00

Health Care Services and Medical Supplies

UnitedHealthcare Medicare Advantage Choice Plan 2 (PPO) 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 $20.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Chiropractic Services $70.00
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)
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 $20.00
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 $165.00
Copayment for Medicare-covered Therapeutic Radiological Services $60.00
Copayment for Medicare-covered X-Ray Services $15.00
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 40%
Copayment for Medicare Covered Lab Services $0.00
Coinsurance for Medicare Covered Diagnostic Radiological Services 40%
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Copayment for Medicare Covered Outpatient X-Ray Services $20.00
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:
$350.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 40%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $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 $30.00 to $40.00
Copayment for Medicare Covered Group Sessions $30.00 to $40.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $350.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per day $350.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $350.00
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 40%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $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 $30.00 to $40.00
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $50.00
Copayment for Routine Foot Care $50.00
  • Maximum 6 visits every year
Prior Authorization Required for Podiatry Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Podiatry Services $70.00 Copayment for Non-Medicare Covered Podiatry Services $70.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 56
$0.00 per day for days 57 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
$225.00 per day for days 1 to 45
$0.00 per day for days 46 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%
Prior Authorization Required for Comprehensive Dental
Prior authorization required
Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 40%

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 $70.00
Coinsurance for Medicare Covered Eyewear 40%
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $70.00

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 $375.00 to $1425.00
  • Maximum 2 Hearing Aids every year
Prior Authorization Required for Hearing Aids
Section B - General 18b Note - NOTE ON COST SHARING: Copays will range from a minimum copay of $375 to a maximum of $1,425 based on features and style. NOTE ON COMBINED COVERAGE FOR HEARING AID BENEFIT: Member may purchase a total of two hearing aids every year.
Prior authorization required
Out-of-Network:

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $70.00
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $70.00
Copayment for Non-Medicare Covered Hearing Aids $375.00

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:
    Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 40%

    Prescription Drug Costs and Coverage

    The UnitedHealthcare Medicare Advantage Choice Plan 2 (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $405 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $405 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail $3.00
    • Preferred mail order N/A
    • Standard mail order N/A
    Generic
    • Standard retail $12.00
    • Preferred mail order N/A
    • Standard mail order N/A
    Annual Drug Deductible $405 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    Generic
    • Standard retail N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    Annual Drug Deductible $405 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard retail $9.00
    • Preferred mail order $0.00
    • Standard mail order $9.00
    Generic
    • Standard retail $36.00
    • Preferred mail order $0.00
    • Standard mail order $36.00