UHC Medicare Advantage TX-0030 (Regional PPO)
Health Insurance Company: UnitedHealthcare®
Medicare Advantage Plan Details
- Rx
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $20 copay per visit
Out-of-network: $50 copay per visit
Out-of-network: $0 copay
Emergency Room
$100 copay per visit (always covered)
Ambulance Coverage
In-network: $290 copay
Out-of-network: $290 copay
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: In-network: $45 copay
Out-of-network: $45 copay
Medicare-covered lab services: In-network: $0 copay
Out-of-network: $0 copay
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): In-network: $0-250 copay
Out-of-network: $0-250 copay
Medicare-covered x-ray services: In-network: $25 copay
Out-of-network: $25 copay
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: In-network: $0-455 copay per visit
Out-of-network: $0-455 copay per visit
Hospitalization Coverage
Inpatient hospital-acute:
In-network: $455 per day for days 1 through 5
$0 per day for days 6 through 90
$0 per day for days 91 and beyond
Out-of-network: $455 per day for days 1 through 5
$0 per day for days 6 and beyond
Inpatient hospital psychiatric:
In-network: $455 per day for days 1 through 4
$0 per day for days 5 through 90
Out-of-network: $455 per day for days 1 through 4
$0 per day for days 5 through 90
Rehabilitation Coverage
Occupational therapy services:
In-network: $0-40 copay
Out-of-network: $40 copay
Physical therapy and speech and language therapy services:
In-network: $0-40 copay
Out-of-network: $40 copay
Urgent Care Coverage
$0-40 copay per visit (always covered)
Skilled Nursing Facility (SNF)
In-network: $0 per day for days 1 through 20
$203 per day for days 21 through 100
Out-of-network: $0 per day for days 1 through 20
$203 per day for days 21 through 100
Mental Health Coverage
Medicare-covered individual sessions: In-network: $0-25 copay
Out-of-network: $15-25 copay
Medicare-covered group sessions: In-network: $15 copay
Out-of-network: $15-25 copay
Dental, Vision, Hearing Benefits
Dental Services
Oral exams: Not covered
Prophylaxis (cleaning): Not covered
Dental x-rays: Not covered
Vision Benefits
Eye exams:
Routine eye exams: In-network: $0 copay
Out-of-network: $0 copay
Eyewear:
Contact Lenses: In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses: In-network: $0 copay
Out-of-network: $0 copay
Hearing Benefits
Hearing exams:
Routine hearing exams: In-network: $0 copay
Out-of-network: $50 copay
Hearing aids:
Hearing aids (all types): In-network: $99-1,249 copay
Out-of-network: $99-1,249 copay
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$4.00 copay (30-day supply)
$12.00 copay (90-day supply)
Tier 2: Generic
$12.00 copay (30-day supply)
$36.00 copay (90-day supply)
Tier 3: Preferred Brand
$47.00 copay (30-day supply)
$141.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$100.00 copay (30-day supply)
$300.00 copay (90-day supply)
Tier 5: Specialty Tier
27% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$12.00 copay (90-day supply)
Tier 2: Generic
$36.00 copay (90-day supply)
Tier 3: Preferred Brand
$141.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$300.00 copay (90-day supply)
Tier 5: Specialty Tier
27% coinsurance (30-day supply)
Rx Drug Coverage - Preferred Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
$131.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$290.00 copay (90-day supply)
Tier 5: Specialty Tier
27% coinsurance (30-day supply)
Plan Links
Ready to Enroll Online?
Or call and get free advice from licensed insurance agents