![]() Routine hearing exam 3 $0 copay, 1 per year $40 copay, combined visits in and out-of-network Home-delivered eyewear available nationwide only through UnitedHealthcare Vision (select products only). Standard single, bifocal, trifocal, or progressive lenses are covered in full. Plan pays up to $300 every year for frames or contact lenses. $40 copay, combined visits in and out-of-network Routine eye exam 3 $0 copay, 1 per year $40 copay, combined visits in and out-of-network $40 copay per visit ($0 copay when outside of the United States) ![]() Urgent care $40 copay per visit ($0 copay when outside of the United States) $40 copay per visit ($0 copay when outside of the United States) Skilled nursing facility $0 copay per day: days 1-20 $0 copay - $40 copay (depending on the service) Preventive services (such as covered screenings, vaccinations, etc.) 2 $0 copay for covered services $0 copay - $40 copay (depending on the service) Preventive services (such as covered screenings, vaccinations, etc.) Outpatient hospital services (including surgery and observation) 2 $295 copay $425 copay Outpatient hospital services (including surgery and observation) Opioid treatment services $0 copay $0 copay Mental health (outpatient) Group: $15 copay Physical, speech or occupational therapy $10 copay per visit $40 copay per visit $0 copay per day after that for unlimited days $0 copay per day after that for unlimited days $425 copay per day: days 1-10 Inpatient hospital care $295 copay per day: days 1-6 Home health care $0 copay 50% of the cost $135 copay per visit ($0 copay when outside of the United States)Īmbulance services $290 copay for ground or air $290 copay for ground or air $0 copay for at least a 3-month supply of Tier 1 medications with preferred home delivery pharmacy from OptumRx.Īmbulatory surgical center 2 $245 copay $425 copayĭiabetes monitoring supplies 2 $0 copay for covered brands 50% of the costĭiagnostic radiology services (such as MRIs, CT scans, etc.)ĭiagnostic radiology services (such as MRIs, CT scans, etc.) $0 - $250 copay $350 copayĭiagnostic tests and procedures, non-radiological (such as EKG/ECG tests, etc.)ĭiagnostic tests and procedures, non-radiological (such as EKG/ECG tests, etc.) $0 copay $35 copayĮmergency care $135 copay per visit ($0 copay when outside of the United States) $135 copay per visit ($0 copay when outside of the United States) Preferred home delivery pharmacy from OptumRx For excluded drugs covered under any enhanced benefit, you pay a cost share. ![]() You pay nothing for Medicare Part D covered drugs. During this payment stage, the plan pays the full cost for your Medicare Part D covered drugs. ![]() NOTE ON PART D CATASTROPHIC COVERAGE STAGE (Post-TrOOP Cost Shares): Once your yearly out-of-pocket drug costs reach $8,000, you move into the Catastrophic Coverage stage. You pay this amount until your total out-of-pocket cost reaches $8,000. You may pay less if your plan has additional coverage in the gap. For all other tiers, you pay 25% of the negotiated price for covered drugs. In this stage, the plan pays its share of the cost of your Tier 1 drugs and you pay your copay or coinsurance. If your plan has an annual deductible, you (or others on your behalf) will pay your drug costs up to the amount of this deductible before moving into the Initial Coverage stage. ![]()
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