Page 92 - Evaluation for Tom Tappan

Medicare Advantage
Medicare Advantage Core Comprehensive
In-Network and Out-of-Network †
In-Network and Out-of-Network †
Ambulance $100 copay $50 copay
Emergency care $75 copay (worldwide) $65 copay (worldwide)
Urgently needed services $65 copay (worldwide) $35 copay (worldwide) Plan information
Annual out-of-pocket $3,000 $600
maximum

Additional benefits and programs not covered by Original Medicare

Medicare Advantage
Medicare Advantage Core
In-Network and Out-of-Network † Comprehensive
In-Network and Out-of-Network †
Routine physical $0 copay; 1 per plan year* $0 copay; 1 per plan year*
Acupuncture $30 copay $25 copay
(Unlimited visits per plan year)* (Unlimited visits per plan year)*
Chiropractic care $30 copay (Up to 20 visits per $20 copay (Up to 20 visits per
plan year)* plan year)*
Foot care – routine $30 copay $25 copay
(up to 6 visits per plan year)* (up to 6 visits per plan year)*

Hearing – routine exam $0 copay $0 copay
(1 exam every 12 months)* (1 exam every 12 months)*
Hearing aids Plan pays up to $500 Plan pays up to $500
(every 3 plan years)* (every 3 plan years)*
Vision – routine $30 copay $25 copay
eye exam (1 exam every 12 months)* (1 exam every 12 months)*
Fitness program Stay active with a basic gym Stay active with a basic gym
through SilverSneakers® membership at a participating membership at a participating
location at no extra cost to you location at no extra cost to you
NurseLine SM Speak with a registered nurse Speak with a registered nurse
(RN) 24 hours a day, 7 days (RN) 24 hours a day, 7 days
a week a week
Virtual Visits Speak to specific doctors Speak to specific doctors
using your computer or mobile using your computer or mobile
device with a $0 copay. Find device with a $0 copay. Find
participating doctors online participating doctors online
at www.UHCRetiree.com/ at www.UHCRetiree.com/
healthplans. healthplans.
† As a member of our plan, you can choose to receive care from out-of-network providers. However,
please note providers that do not contract with us are under no obligation to treat you, except in
emergency situations. Our plan will cover services from either network or out-of-network providers,
as long as the services are covered benefits and are medically necessary. Because you are a
member of the UnitedHealthcare® Group Medicare Advantage (PPO) plan, you can see any
provider (in-network or out-of-network) at the same cost share, as long as they accept the plan and
have not opted out of Medicare.
*Benefits are combined in and out-of-network.