UHC Dual Complete LA-S003 (HMO-POS D-SNP) (2024)

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Footnotes

² Amounts may vary depending on the level of care provided or the type of health care services you receive. 
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³ Benefits, features and/or devices may vary by plan/area. Limitations and exclusions apply. See the Summary of Benefits (PDF) in the Plan Documents section for details. 

⁴ Benefits, features and/or devices may vary by plan/area. Limitations and exclusions apply. See the Evidence of Coverage (PDF) in the Plan Documents section for details. 

⁵ This document is the Annual Notice of Changes for this plan. If you are a current plan member and have been switched to a different plan, this document may not apply to you. If you have any questions, please call Customer Service at the number on your member ID card. 

⁶ Coverage Gap Stage: 

NOTE: Only applies to plans with prescription drug coverage. 

Amounts displayed do not include taxes or injection fees. 

During the Coverage Gap, amounts displayed for brand name drugs include a 70% manufacturer discount. However, this discount is based on pharmaceutical manufacturers' participation and may not apply to all brand drugs. You pay 25% of the total cost for brand name drugs, for any drug tier during the Coverage Gap. 

The 25% drug coinsurance within the Coverage Gap is based on an assessment that the drug is defined as a generic drug according to Part D rules. 

If your drug is not eligible for coverage under Medicare Part D, you will pay the full cost of the drug. 

⁷ Optum Home Delivery: 

NOTE: Only applies to plans with prescription drug coverage. 

2024 Savings 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. 

Optum Rx is an affiliate of UnitedHealthcare Insurance Company. Optum Home Delivery is a service of Optum Rx pharmacy. You are not required to use Optum Home Delivery to obtain at least a 3-month supply of your maintenance medication. If you have not used Optum Home Delivery, you must approve the first prescription order sent directly from your doctor to Optum Rx 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 Rx anytime at 1-877-266-4832 (TTY 711). 
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$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.  

Disclaimers 

Annual plan statement:
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Benefits, premium and/or copayments/coinsurance may change on January 1 of each year.

PPO plans: 

Out-of-network/non-contracted providers are under no obligation to treat UnitedHealthcare 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. 
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Coverage determinations and appeals process:
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Find important information about Medicare Advantage coverage determinations and appeals, quality assurance policies, grievances, drug conditions and limitations. View Medicare Advantage (Part C) coverage determinations and appeals process. 

Learn about prescription drug coverage determinations and appeals, prior authorization criteria, step therapy criteria and the 60-day formulary change notice. View prescription drug (Part D) coverage determinations and appeals process. 

View the UnitedHealthcare Prescription Drug Transition Process. 

Information for plans with prescription drug coverage:

The list of covered drugs is updated monthly. 

NOTE: Prescription drugs that are not covered by the plan or that cannot be provided as part of standard Medicare prescription drug coverage are shown as "not covered". 

Copay or coinsurance amounts may change if you have a limited income. 

The drug costs displayed are estimates and may vary based on the specific quantity, strength and/or dosage of the medication and the pharmacy you use. It may be important to look beyond your current needs at the value of having Medicare prescription drug insurance. Enrolling when you become eligible will help give you peace of mind, should your drug needs become more significant in the future. It may also help you avoid the Medicare late enrollment penalty. 

Drugs and prices may vary between pharmacies and are subject to change during the plan year. Prices are based on quantity filled at the pharmacy. Quantities may be limited by pharmacy based on their dispensing policy or by the plan based on Quantity Limit requirements; if prescription is in excess of a limit, copay amounts may be higher. 

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. 

All network pharmacies may not be listed in this directory. Inclusion of a pharmacy does not guarantee that the pharmacy is open, is at the same location as listed in this online directory or is included in the network. The pharmacy network may change at any time. You will receive notice when necessary. Pharmacies on this list are called “network pharmacies” because UnitedHealthcare has made arrangements with them to provide prescription drugs to Plan members. In most cases, your prescriptions are covered under your plan only if they are filled at a network pharmacy or through our mail order pharmacy service. You are not required to continue using the same pharmacy to fill your prescriptions and may switch to any other network pharmacy. Prescriptions can be filled at non-network pharmacies under certain circ*mstances as described in your Evidence of Coverage. To get a complete description of your prescription coverage, including how to fill your prescriptions, please review the Evidence of Coverage and your plan’s formulary. Please contact UnitedHealthcare for details. 

UnitedHealthcare has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. 

The pharmacy directory is current as of the first Sunday of each month. 

NOTE: If you are receiving Extra Help from Medicare, your copays may be lower or you may have no copays. 

Enrollment disclaimer information:

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in these plans depends on the plan’s contract renewal with Medicare. UnitedHealthcare Insurance Company pays 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 recommendations for individuals. UnitedHealthcare contracts directly with Walgreens for this plan; AARP and its affiliates are not parties to that contractual relationship. 

Dental (routine/comprehensive):

Benefits, features and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply. 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. Provider network may vary in local market. Dental network size based on Zelis Network360, May 2023.

Hearing:

Benefits, features, and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply. Other hearing exam providers are available in the UnitedHealthcare network. The plan only covers hearing aids from a UnitedHealthcare Hearing network provider. Provider network size may vary by local market.

Network:

Provider network may vary in local market. Provider network size based on Zelis Network360, May 2023.

Over-the-Counter (OTC):

Benefits, features and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply. Food/OTC/Utilities benefits have expiration timeframes. Call your plan or review your Evidence of Coverage (EOC) for more information.

PERS:

Benefits, features and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply. You must have a working landline and/or cellular phone coverage to use PERS.

Renew Active:

The Renew Active® Program varies by plan/area and may not be available on all plans. Participation in the Renew Active program is voluntary. Consult your doctor prior to beginning an exercise program or making changes to your lifestyle or health care routine. Renew Active includes standard fitness membership and other offerings.

Fitness membership equipment, classes, personalized fitness plans, caregiver access and events may vary by location. Certain services, discounts, classes, events and online fitness offerings are provided by affiliates of UnitedHealthcare Insurance Company or other third parties not affiliated with UnitedHealthcare. Participation in these third-party services are subject to your acceptance of their respective terms and policies. UnitedHealthcare is not responsible for the services or information provided by third parties. The information provided through these services is for informational purposes only and is not a substitute for the advice of a doctor.

Gym network may vary in local market and plan. Gym network size is based on comparison of competitor’s website data as of May 2023.

Footnotes

² Amounts may vary depending on the level of care provided or the type of health care services you receive. 

³ Benefits, features and/or devices may vary by plan/area. Limitations and exclusions apply. See the Summary of Benefits (PDF) in the Plan Documents section for details. 

⁴ Benefits, features and/or devices may vary by plan/area. Limitations and exclusions apply. See the Evidence of Coverage (PDF) in the Plan Documents section for details. 

⁶ Coverage Gap Stage: 

NOTE: Only applies to plans with prescription drug coverage. 

Amounts displayed do not include taxes or injection fees. 

The 25% drug coinsurance within the Coverage Gap is based on an assessment that the drug is defined as a generic drug according to Part D rules. 

If your drug is not eligible for coverage under Medicare Part D, you will pay the full cost of the drug. 

⁷ Optum Home Delivery: 

NOTE: Only applies to plans with prescription drug coverage. 

2024 Savings Benefit

Disclaimers 

Annual plan statement:
\n

Benefits, premium and/or copayments/coinsurance may change on January 1 of each year.

PPO plans: 

Coverage determinations and appeals process:
\n

Learn about prescription drug coverage determinations and appeals, prior authorization criteria, step therapy criteria and the 60-day formulary change notice. View prescription drug (Part D) coverage determinations and appeals process. 

View the UnitedHealthcare Prescription Drug Transition Process. 

Information for plans with prescription drug coverage:

The list of covered drugs is updated monthly. 

NOTE: Prescription drugs that are not covered by the plan or that cannot be provided as part of standard Medicare prescription drug coverage are shown as "not covered". 

Copay or coinsurance amounts may change if you have a limited income. 

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. 

UnitedHealthcare has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. 

The pharmacy directory is current as of the first Sunday of each month. 

NOTE: If you are receiving Extra Help from Medicare, your copays may be lower or you may have no copays. 

Enrollment disclaimer information:

Dental (routine/comprehensive):

Hearing:

Network:

Footnotes

² This document is the Annual Notice of Changes for this plan. If you are a current plan member and have been switched to a different plan, this document may not apply to you. If you have any questions, please call Customer Service at the number on your member ID card. 
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³ During the Coverage Gap, amounts displayed for brand name drugs include a 70% manufacturer discount. However, this discount is based on pharmaceutical manufacturers' participation and may not apply to all brand drugs. You pay 25% of the total cost for brand name drugs, for any drug tier during the Coverage Gap. 

The 25% drug coinsurance within the Coverage Gap is based on an assessment that the drug is defined as a generic drug according to Part D rules. 

If your drug is not eligible for coverage under Medicare Part D, you will pay the full cost of the drug. 

Disclaimers 

Annual plan statement:
\n

Benefits, premium and/or copayments/coinsurance may change on January 1 of each year.

AARP Medicare Rx Walgreens plans:

Member may use any pharmacy in the network but may not receive the same pricing as Walgreens or Duane Reade, the plan's preferred retail pharmacies. Walgreens pharmacies may not be available in all areas. Duane Reade is only available in NY and NJ. Tier 1 $2 generic cost share applies to all drug payment stages except Catastrophic Drug Payment Stage where the member pays $0. Tier 2-5 member cost share applies after deductible. $15 or more savings for the AARP Medicare Rx Walgreens plan applies to Tier 1 drugs when filled at a Walgreens or Duane Reade preferred retail pharmacy compared to a standard network pharmacy. 
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 AARP Medicare Rx Preferred, AARP Medicare Rx Saver, AARP Medicare Rx Basic:
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Member may use any pharmacy in the network but may not receive preferred retail pharmacy pricing. Pharmacies in the Preferred Retail Pharmacy Network may not be available in all areas. Copays apply after deductible. Note: The Preferred Retail Pharmacy Network is not available in Guam, American Samoa, U.S. Virgin Islands or Northern Mariana Islands. 

2024 -AARP Medicare Rx Preferred, AARP Medicare Rx Saver, AARP Medicare Rx Basic and AARP Medicare Rx Walgreens:
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AARP Medicare Rx Preferred from UHC (PDP)'s pharmacy network includes limited lower-cost pharmacies in rural AK, MT, NE, ND, SD and WY. There are an extremely limited number of preferred cost share pharmacies in suburban MT. AARP Medicare Rx Saver from UHC (PDP)’s pharmacy network includes limited lower-cost pharmacies in rural AK. AARP Medicare Rx Basic from UHC (PDP)’s pharmacy network includes limited lower-cost pharmacies in rural MT, NE, ND, SD and WY. There are an extremely limited number of preferred cost share pharmacies in suburban MT. AARP Medicare Rx Walgreens from UHC (PDP)’s pharmacy network includes limited lower-cost pharmacies in urban ND; suburban HI and PA; and rural AK, AR, HI, IA, ID, KS, MN, MS, MT, NE, OK, PA, SD and WY. There are an extremely limited number of preferred cost share pharmacies in suburban MT, ND and rural ND. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, pleasecall usorconsult the online pharmacy directory. 
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NOTE: If you are receiving Extra Help from Medicare, your copays may be lower or you may have no copays. 

Optum Mail Home Delivery: 

2024 Savings Benefit

NOTE: Optum Home Delivery is not available in Guam, American Samoa, U.S. Virgin Islands or Northern Mariana Islands. 
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More Information:

The list of covered drugs is updated monthly. 

NOTE: Prescription drugs that are not covered by the plan or that cannot be provided as part of standard Medicare prescription drug coverage are shown as "not covered" in the chart. 

Copay or coinsurance amounts may change if you have  a limited income. 

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

The pharmacy directory is current as of the first Sunday of each month. 

All pharmacies may not be listed in this directory. Inclusion of a pharmacy does not guarantee that the pharmacy is open, is at the same location as listed in this online directory or is included in the network. The pharmacy network may change at any time. You will receive notice when necessary. Pharmacies on this list are called “network pharmacies” because UnitedHealthcare has made arrangements with them to provide prescription drugs to Plan members. In most cases, your prescriptions are covered under your plan only if they are filled at a network pharmacy or through our mail order pharmacy service. You are not required to continue using the same pharmacy to fill your prescriptions and may switch to any other network pharmacy. Prescriptions can be filled at non-network pharmacies under certain circ*mstances as described in your Evidence of Coverage. To get a complete description of your prescription coverage, including how to fill your prescriptions, please review the Evidence of Coverage and your plan’s formulary. Please contact UnitedHealthcare for details. 

UnitedHealthcare has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. 

View the UnitedHealthcare Prescription Drug Transition Process. 

Enrollment disclaimer information:

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare. UnitedHealthcare Insurance Company pays 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 recommendations for individuals. AARP Medicare Rx Walgreens (PDP) plans: UnitedHealthcare contracts directly with Walgreens for this plan; AARP and its affiliates are not parties to that contractual relationship. 

This information is not a complete description of benefits. Call us  for more information. 

This information is available for free in other languages. Please  contact  Customer Service for additional information. 

Esta información está disponible sin costo en otros idiomas. Para obtener más información comuníquese  con nuestro Servicio al Cliente.

本資訊可以其他語言免費提供。如需更多資訊，請 聯絡客戶服務部。 

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Find out about this plan’s copays for primary care providers and specialists.

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Learn about this plan's prescription drug coverage and costs. Enter your prescriptions to see what they'd cost with this plan.

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Important documents that provide the details you need about this plan's coverage and benefits, prescription drugs, enrollment, providers and more.

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See how much you'll pay for this plan including your premium, deductible and maximum out-of-pocket costs.

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Learn about this plan’s dental coverage options and costs.

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Learn more about what you pay, what this plan covers and how we can help you find the right plan.

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See this plan's benefits, costs and copays. For full plan details, see the Evidence of Coverage orSummary of Benefits under the Plan Documents section.

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here to help","getHelp":"Get one-on-one help from UnitedHealthcare.","daysAWeek":"8 a.m. to 8 p.m., 7 days a week","tty":"/ TTY 711","findASalesAgent":"Find a sales agent in your area","illustrationSupport":"/content/dam/commontools/vpp/redesign/images/illustration-support-rgb-full@2x.png"},"isnp":{"call":"Call","externalLinkIcon":"/content/dam/commontools/vpp/redesign/icons/external-blue-icon@2x.png","wereHereToHelp":"We're here to help","getHelp":"Get one-on-one help from UnitedHealthcare.","daysAWeek":" 7 a.m. to 7 p.m., 7 days a week","tty":"/ TTY 711","findASalesAgent":"Find a sales agent in your area","illustrationSupport":"/content/dam/commontools/vpp/redesign/images/illustration-support-rgb-full@2x.png","tfn":"/content/dam/MRD/content-fragments/common-tools-vpp/global/enroll-by-phone"},"iesnp":{"call":"Call","externalLinkIcon":"/content/dam/commontools/vpp/redesign/icons/external-blue-icon@2x.png","wereHereToHelp":"We're here to help","getHelp":"Get one-on-one help from 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What is an HMO? Medicare Health Maintenance Organization (HMO) plans cover care you receive through a network of local doctors and hospitals that coordinate your care.

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What is PPO? Preferred Provider Organization (PPO) plans allow you to visit providers who are in or out of the plan's network. For services received outside of the network, you generally have higher copayment and coinsurance costs.

\n"},"pos":{"DSNP":false,"hideplansummary":false,"HMOPOS":true,"hideplandetails":true,"PFFS":false,"hideplancompare":true,"HMO":false,"CSNP":false,"PPO":false,"ISNP":false,"tooltipvalue":"

What is HMO-POS? A type of HMO plan, Point of Service (POS) plans let you receive certain services from doctors or hospitals that are not in the plans network, generally at a higher copayment or coinsurance.

\n"},"pffs":{"DSNP":false,"hideplansummary":false,"HMOPOS":false,"hideplandetails":true,"PFFS":true,"hideplancompare":true,"HMO":false,"CSNP":false,"PPO":false,"ISNP":false,"tooltipvalue":"

What is PFFS? A Private Fee-for-Service (PFFS) plan is a Medicare Advantage plan that can be a network or non-network plan. UnitedHealthcare only offers non-network PFFS plans, which give members the freedom to use any Medicare-eligible doctor or hospital who agrees to accept the plan's terms and conditions of payment. No referrals or prior authorizations are required for covered services.

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What is an HMO? Medicare Health Maintenance Organization (HMO) plans cover care you receive through a network of local doctors and hospitals that coordinate your care.

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\n"}},"toolTipConfig":{"master":{"hideplansummary":false,"hideplandetails":false,"hideplancompare":false},"select_insulin_drugs":{"benefitname":"Insulin Demo (M118)","hideplansummary":true,"hideplandetails":true,"hideplancompare":true,"tooltipvalue":"

For Chronic Special Needs plans: You will pay a maximum of $25 for each 1-month supply of Part D select insulin drug through all coverage stages. 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.

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UHC Dual Complete LA-S003 (HMO-POS D-SNP)

Monthly premium: $0

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Monthly premium
^$0
$0

Primary care provider (PCP)
^$0 copay
$0 copay

Out-of-pocket maximum
^$0
$0

Estimated Annual Drug Cost

Discover the Benefits

Food, OTC and Utilities
$250 credit every month to pay for healthy food, OTC products and utility bills

Dental benefits
$3,500 allowance for covered dental services like cleanings, fillings, crowns, root canals, extractions and dentures

Routine transportation
$0 copay for 72 one-way rides to or from doctor visits or the pharmacy to get prescriptions

Eligibility

Special eligibility requirement ⁴	Must be eligible for both Medicare and Medicaid and either be a Qualified Medicare Beneficiary or have Full Medicaid coverage in one of the following categories in LA: FBDE, QMB, QMB PLUS, SLMB PLUS.
Special eligibility requirement ⁴ Must be eligible for both Medicare and Medicaid and either be a Qualified Medicare Beneficiary or have Full Medicaid coverage in one of the following categories in LA: FBDE, QMB, QMB PLUS, SLMB PLUS.Must be eligible for both Medicare and Medicaid and either be a Qualified Medicare Beneficiary or have Full Medicaid coverage in one of the following categories in LA: FBDE, QMB, QMB PLUS, SLMB PLUS.

General Plan Costs

See how much you'll pay for this plan including your premium, deductible and maximum out-of-pocket costs.

Costs	What you'll pay
Monthly premium	$0
Monthly premium $0$0
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. x Close Popup	$0
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. x Close Popup $0
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. x Close Popup	$0
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. x Close Popup $0

Doctor visits

Find out about this plan’s copays for primary care providers and specialists.

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.

Dental coverage

Learn about this plan’s dental coverage options and costs.

Medical benefit information

See this plan's benefits, costs and copays. For full plan details, see the Evidence of Coverage orSummary of Benefits under the Plan Documents section.

Extra benefits and programs

Plan documents

Important documents that provide the details you need about this plan's coverage and benefits, prescription drugs, enrollment, providers and more.