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UHC Nursing Home Plan EX-F003 (PPO I-SNP)
- Monthly premium
- Primary care provider (PCP)
- Out-of-pocket maximum
- Estimated Annual Drug Cost
Enroll by phone: 1-877-840-0872 / TTY 711
Call a UnitedHealthcare sales agent to enroll, 7 a.m. to 7 p.m. CT, 7 days a week.
Discover the Benefits
Dental benefits
- $3,250 allowance for covered dental services like cleanings, fillings, crowns, root canals, extractions and dentures
Routine transportation
- $0 copay for 36 one-way rides to or from doctor visits or the pharmacy to get prescriptions
OTC Credit
- $290 credit every quarter for OTC products like pain relievers, cold remedies and vitamins in-store or online
General plan costs
See how much you'll pay for this plan including your premium, deductible and maximum out-of-pocket costs.
| Costs | In-network - What you'll pay | Out-of-network - What you'll pay |
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| Monthly premium | $33.50 | |
| Monthly premium $33.50$33.50 | ||
Annual medical deductible
Annual medical deductible
The pre-set, fixed amount you must pay for health care costs before the insurance company or Medicare begins to pay. Please see your Evidence of Coverage for details.
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No deductible | No deductible |
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Annual medical deductible
Annual medical deductible
The pre-set, fixed amount you must pay for health care costs before the insurance company or Medicare begins to pay. Please see your Evidence of Coverage for details.
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Out-of-pocket maximum
Out-of-pocket maximum
This is the highest amount of money you have to pay out of your pocket for cost sharing (copayments and coinsurance) charged for certain covered services during a calendar year. Not all copayments or coinsurance amounts you pay apply toward the annual out-of-pocket maximum. See the plan’s Evidence of Coverage for more information.
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$2,300 | $5,600 combined in and out-of-network |
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Out-of-pocket maximum
Out-of-pocket maximum
This is the highest amount of money you have to pay out of your pocket for cost sharing (copayments and coinsurance) charged for certain covered services during a calendar year. Not all copayments or coinsurance amounts you pay apply toward the annual out-of-pocket maximum. See the plan’s Evidence of Coverage for more information.
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Doctor visits
Find out about this plan's copays for primary care providers and specialists.
| Costs | In-network - what you'll pay | Out-of-network - what you'll pay |
|---|---|---|
| Primary care provider (PCP) | $0 copay | 30% of the cost |
| Primary care provider (PCP) $0 copay30% of the cost | ||
| Specialist | $0 copay - 20% of the cost | 30% of the cost |
| Specialist $0 copay - 20% of the cost30% of the cost | ||
| Virtual visits | $0 copay to talk with a telehealth provider online through live audio and video. | |
| Virtual visits $0 copay to talk with a telehealth provider online through live audio and video.$0 copay to talk with a telehealth provider online through live audio and video. | ||
| Annual routine physical | $0 copay, 1 per year | 30% of the cost, combined visits in and out-of-network |
| Annual routine physical $0 copay, 1 per year30% of the cost, combined visits in and out-of-network | ||
| Preventive services (such as covered screenings, vaccinations, etc.) | $0 copay for covered services | $0 copay - 30% of the cost (depending on the service) |
| Preventive services (such as covered screenings, vaccinations, etc.) $0 copay for covered services$0 copay - 30% of the cost (depending on the service) | ||
| Mental health (outpatient) |
Group: 20% of the cost Individual: 20% of the cost |
Group: 30% of the cost Individual: 30% of the cost |
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Mental health (outpatient)
Group: 20% of the cost Individual: 20% of the cost Group: 30% of the cost Individual: 30% of the cost |
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| Opioid treatment services | $0 copay | $0 copay |
| Opioid treatment services $0 copay$0 copay | ||
Prescription drug benefits
Learn about this plan's prescription drug coverage and costs. Enter your prescriptions to see what they'd cost with this plan.
| Costs | What you'll pay |
|---|---|
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Annual prescription deductible
Annual prescription deductible
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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$545 If you qualify for Extra Help in 2024, then your annual prescription deductible will be $0. |
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Annual prescription deductible
Annual prescription deductible
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.
If you qualify for Extra Help in 2024, then your annual prescription deductible will be $0. |
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| Covered Insulin |
Network pharmacy (30-day) No more than $35 copay Standard mail order pharmacy (100-day) No more than $105 copay |
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Covered Insulin
Network pharmacy (30-day) No more than $35 copay Standard mail order pharmacy (100-day) No more than $105 copay |
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| Initial Coverage stage - no Extra Help |
Network pharmacy (30-day) 25% coinsurance Standard mail order pharmacy (100-day) 25% coinsurance |
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Initial Coverage stage - no Extra Help
Network pharmacy (30-day) 25% coinsurance Standard mail order pharmacy (100-day) 25% coinsurance |
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| Initial Coverage stage - if you qualify for Extra Help |
Generic (including brand drugs treated as generic) $0, $1.55 or $4.50 copay All other drugs $0, $4.60 or $11.20 copay |
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Initial Coverage stage - if you qualify for Extra Help
Generic (including brand drugs treated as generic) $0, $1.55 or $4.50 copay All other drugs $0, $4.60 or $11.20 copay |
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| Coverage Gap stage | In this stage, you pay 25% of the negotiated price for covered drugs. You pay less if your plan has additional coverage in the gap. You pay this amount until your total out-of-pocket cost reaches $8,000. |
| Coverage Gap stage In this stage, you pay 25% of the negotiated price for covered drugs. You pay less if your plan has additional coverage in the gap. You pay this amount until your total out-of-pocket cost reaches $8,000. | |
| Catastrophic Coverage stage | After your total out-of-pocket drug costs reach $8,000, you won't pay anything for Medicare Part D covered drugs for the rest of the plan year. For excluded drugs covered under any enhanced benefit, you pay a cost share. |
| Catastrophic Coverage stage After your total out-of-pocket drug costs reach $8,000, you won't pay anything for Medicare Part D covered drugs for the rest of the plan year. For excluded drugs covered under any enhanced benefit, you pay a cost share. |
Dental coverage
Learn about this plan's dental coverage options and costs.
| Costs | What you'll pay |
|---|---|
| Routine dental |
$3,250 per year for covered dental services $0 copay for covered network preventive services such as oral exams, routine cleanings, X-rays and fluoride $0 copay for covered network comprehensive services such as fillings, crowns, root canals, extractions, bridges and dentures You will have access to Medicare Advantage's largest dental network, or you can choose any dentist. Seeing a network dentist may save you money. |
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Routine dental
$3,250 per year for covered dental services $0 copay for covered network preventive services such as oral exams, routine cleanings, X-rays and fluoride $0 copay for covered network comprehensive services such as fillings, crowns, root canals, extractions, bridges and dentures You will have access to Medicare Advantage's largest dental network, or you can choose any dentist. Seeing a network dentist may save you money. |
Medical benefit information
See this plan's benefits, costs and copays. For full plan details, see the Evidence of Coverage or Summary of Benefits under the Plan Documents section.
| Costs | In-network - What you'll pay | Out-of-network - What you'll pay |
|---|---|---|
| Urgent care | $40 copay per visit always covered when you need it | |
| Urgent care $40 copay per visit always covered when you need it$40 copay per visit always covered when you need it | ||
| Emergency care | $100 copay per visit always covered when you need it | |
| Emergency care $100 copay per visit always covered when you need it$100 copay per visit always covered when you need it | ||
| Ambulance services | 20% of the cost for ground or air | 20% of the cost for ground or air |
| Ambulance services 20% of the cost for ground or air20% of the cost for ground or air | ||
| Inpatient hospital care | $1,628 per stay for unlimited days | $1,628 per stay for unlimited days |
| Inpatient hospital care $1,628 per stay for unlimited days$1,628 per stay for unlimited days | ||
| Outpatient hospital services (including surgery and observation) | $0 - 20% of the cost | 30% of the cost |
| Outpatient hospital services (including surgery and observation) $0 - 20% of the cost30% of the cost | ||
| Ambulatory surgical center | $0 - 20% of the cost | 30% of the cost |
| Ambulatory surgical center $0 - 20% of the cost30% of the cost | ||
| Physical, speech or occupational therapy | $0 copay per visit | 30% of the cost per visit |
| Physical, speech or occupational therapy $0 copay per visit30% of the cost per visit | ||
| Lab services | $0 copay | $0 copay |
| Lab services $0 copay$0 copay | ||
| Outpatient X-rays | $0 copay | 30% of the cost |
| Outpatient X-rays $0 copay30% of the cost | ||
| Diagnostic tests and procedures, non-radiological (such as EKG/ECG tests, etc.) | 20% of the cost | 30% of the cost |
| Diagnostic tests and procedures, non-radiological (such as EKG/ECG tests, etc.) 20% of the cost30% of the cost | ||
| Diagnostic radiology services (such as MRIs, CT scans, etc.) | $0 - 20% of the cost | 30% of the cost |
| Diagnostic radiology services (such as MRIs, CT scans, etc.) $0 - 20% of the cost30% of the cost | ||
| Skilled nursing facility | $0 copay per day: days 1-100 | 30% of the cost |
| Skilled nursing facility $0 copay per day: days 1-10030% of the cost | ||
| Home health care | $0 copay | 30% of the cost |
| Home health care $0 copay30% of the cost | ||
| Diabetes monitoring supplies | 20% of the cost | 30% of the cost |
| Diabetes monitoring supplies 20% of the cost30% of the cost | ||
Extra benefits and programs
See more of the benefits and programs offered by this plan that are not provided under Original Medicare. For full plan details, see the Evidence of Coverage or Summary of Benefits under the Plan Documents section.
| Costs | In-network - What you'll pay | Out-of-network - What you'll pay |
|---|---|---|
| Routine eye exam | $0 copay, 1 per year | 30% of the cost, combined visits in and out-of-network |
| Routine eye exam $0 copay, 1 per year30% of the cost, combined visits in and out-of-network | ||
| Routine eyewear |
$0 copay Plan pays up to $300 every year for frames or contact lenses. Standard single, bifocal, trifocal, or progressive lenses are covered in full. Home-delivered eyewear available nationwide only through UnitedHealthcare Vision (select products only). |
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Routine eyewear
$0 copay Plan pays up to $300 every year for frames or contact lenses. Standard single, bifocal, trifocal, or progressive lenses are covered in full. Home-delivered eyewear available nationwide only through UnitedHealthcare Vision (select products only).$0 copay Plan pays up to $300 every year for frames or contact lenses. Standard single, bifocal, trifocal, or progressive lenses are covered in full. Home-delivered eyewear available nationwide only through UnitedHealthcare Vision (select products only). |
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| Routine hearing exam | $0 copay, 1 per year | 30% of the cost, combined visits in and out-of-network |
| Routine hearing exam $0 copay, 1 per year30% of the cost, combined visits in and out-of-network | ||
| Hearing aids | $2,000 allowance for a broad selection of OTC and brand-name prescription hearing aids through UnitedHealthcare Hearing, up to 2 hearing aids every year | |
| Hearing aids $2,000 allowance for a broad selection of OTC and brand-name prescription hearing aids through UnitedHealthcare Hearing, up to 2 hearing aids every year$2,000 allowance for a broad selection of OTC and brand-name prescription hearing aids through UnitedHealthcare Hearing, up to 2 hearing aids every year | ||
| OTC credit | $290 credit per quarter to buy covered OTC products. | |
| OTC credit $290 credit per quarter to buy covered OTC products.$290 credit per quarter to buy covered OTC products. | ||
| Routine transportation | $0 copay for 36 one-way trips to or from plan approved locations. | 75% of the cost |
| Routine transportation $0 copay for 36 one-way trips to or from plan approved locations.75% of the cost | ||
| Routine foot care | $0 copay, 8 visits per year | 30% of the cost, combined visits in and out-of-network |
| Routine foot care $0 copay, 8 visits per year30% of the cost, combined visits in and out-of-network | ||
Plan documents
Important documents that provide the details you need about this plan's coverage and benefits, prescription drugs, enrollment, providers and more.
| General Plan Information |
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General Plan Information
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| Provider Directory | |
| Provider Directory | |
| Prescription Drug Coverage |
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Prescription Drug Coverage
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| Pharmacy Directory | |
| Pharmacy Directory |
| General Plan Information |
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General Plan Information
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| Provider Directory |
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Provider Directory
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| Prescription Drug Coverage |
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Prescription Drug Coverage
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| Pharmacy Directory | |
| Pharmacy Directory |
Footnotes & disclaimers
Footnotes
1Savings benefit
Savings apply during the Initial Coverage period, which begins after the payment of your required deductible (if any) and ends when the total cost of your drugs (paid by UnitedHealthcare, you and others) reaches $5,030 (2024).
Optum Home Delivery Pharmacy and Optum Rx are affiliates of UnitedHealthcare Insurance Company. You are not required to use Optum Home Delivery Pharmacy for your regular medication. There may be other pharmacies in our network. If you have not used Optum Home Delivery Pharmacy, you must approve the first prescription order sent directly from your doctor before it can be filled. New prescriptions from the pharmacy should arrive within ten business days from the date the completed order is received, and refill orders should arrive in about seven business days. Contact Optum Home Delivery Pharmacy anytime at 1-877-266-4832 / TTY 711, 8 a.m. to 8 p.m., 7 days a week.
$0 copays may be restricted to preferred home delivery prescriptions during the initial coverage phase and may not apply during the coverage or catastrophic stage. Benefits vary by plan/area. Limitations and exclusions apply.
Disclaimer information
Enrollment Disclaimer Information:
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in these plans depends on the plan’s contract renewal with Medicare. UnitedHealthcare Insurance Company paid royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers. You do not need to be an AARP member to enroll. AARP encourages you to consider your needs when selecting products and does not make specific product or pharmacy recommendations for individuals. UnitedHealthcare contracts directly with Walgreens for this plan; AARP and its affiliates are not parties to that contractual relationship.
Extra Help:
If you receive Extra Help from Medicare, your copays may be lower or you may have no copays.
Featured Benefits:
- Benefits, features and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply.
- 2024: Nurse Hotline not for use in emergencies, for informational purposes only.
- Other hearing exam providers are available in the UnitedHealthcare network. The plan only covers hearing aids from a UnitedHealthcare Hearing network provider.
- For Chronic Special Needs Plans - You will pay a maximum of $25 for each 1-month supply of Part D covered insulin drug through all coverage stages, except the Catastrophic drug payment stage where you pay $0.
- For All Other Plans - You will pay a maximum of $35 for each 1-month supply of Part D covered insulin drug through all coverage stages, except the Catastrophic drug payment stage where you pay $0.
- Food, OTC and utility benefits have expiration timeframes. Call your plan or review your Evidence of Coverage (EOC) for more information.
- Eligibility for the healthy food and utilities benefit under the Value-Based Insurance Design model is limited to members with Extra Help from Medicare and will be determined after enrollment.
- For C-SNP: The healthy food benefit is a special supplemental benefit only available to chronically ill enrollees with a qualifying condition, such as diabetes, chronic heart failure and/or cardiovascular disorders, and who also meet all applicable plan coverage criteria. Contact us for details.
- For D-SNP, TN only: The healthy food benefit is a special supplemental benefit only available to chronically ill enrollees with a qualifying condition, such as high blood pressure, high cholesterol, chronic and disabling mental health conditions, diabetes and/or cardiovascular disorders, and who also meet all applicable plan coverage criteria. There may be other qualified conditions not listed. Contact us for details.
- 2024: You must have a working landline and/or cellular phone coverage to use PERS.
- The fitness benefit includes a standard fitness membership. The information provided is for informational purposes only and is not medical advice. Consult your doctor prior to beginning an exercise program or making changes to your lifestyle or health care routine. Gym network may vary in local market and plan.
- If your plan offers out-of-network dental coverage and you see an out-of-network dentist, you might be billed more. Network size varies by local market.
- Routine transportation not for use in emergencies.
- Virtual visits may require video-enabled smartphone or other device. Not for use in emergencies. Not all network providers offer virtual care.
- $0 copays may be restricted to preferred home delivery prescriptions during the initial coverage phase and may not apply during the Catastrophic stage. Optum® Home Delivery Pharmacy and Optum Rx are affiliates of the UnitedHealthcare Insurance Company. You are not required to use Optum Home Delivery Pharmacy for medications you take regularly. There may be other pharmacies in your network.
The Medicare Prescription Payment Plan:
Starting Jan. 1, 2025, if you spend more than $2,000 for covered Part D prescription drugs each year, you may want to participate in the Medicare Prescription Payment Plan. This payment plan spreads your out-of-pocket prescription drug costs over the remainder of the calendar year. Learn more about the Medicare Prescription Payment Plan.
Out-of-network:
Out-of-network/non-contracted providers are under no obligation to treat members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
State-Level Medicaid, D-SNP Disclaimer:
D-SNP and C-SNP: The values shown in-network represent a range based upon the amount of the Medicare Parts A and B plan cost sharing covered by the state. Depending on your Medicaid eligibility, your Medicaid program may have cost sharing. For complete information, and for costs for those without Medicare Parts A and B plan cost sharing covered by the state, and applicable Medicaid cost sharing, please refer to your Summary of Benefits or Evidence of Coverage. Limitations, exclusions, and restrictions may apply.
Other Languages:
This information is available for free in other languages. Please contact Customer Service for additional information.
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