Your plan details for
06752 Litchfield County

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UHC Medicare Advantage Patriot No Rx CT-MA01 (HMO-POS)

The information provided in this document may be subject to change over time and may become outdated. For the most current and up-to-date information, please refer to our website at UHC.com/medicare.

Discover the benefits

  • Dental benefits

    $0 copay for network dental such as exams, x-rays and routine cleanings

  • OTC credit

    $40 credit every quarter for OTC products in-store or online

  • Routine vision benefits

    $200 allowance for eyewear, plus $0 copay for a routine eye exam and lenses

Explore the plan details

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Explore the plan details

Doctor visits

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

Primary care provider (PCP)

$0 copay
In-network

Specialist

$40 copay
In-network

Virtual visits

$0 copay to talk with a network telehealth provider online through live audio and video.

Annual routine physical

$0 copay 1 per year
In-network

Preventive services (such as covered screenings, vaccinations, etc.)

$0 copay for covered services
In-network

Mental health (outpatient)

Group: $15 copayIndividual: $25 copay
In-network

Opioid treatment services

$0 copay
In-network

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.

Inpatient hospital care

$425 copay per day: days 1-7$0 copay per day: days 8 and beyond for unlimited days
In-network

Skilled nursing facility

$0 copay per day: days 1-20$203 copay per day: days 21-100
In-network

Outpatient hospital services (including surgery and observation)

$425 copay
In-network

Ambulatory surgical center

$375 copay
In-network

Physical and speech therapy

$40 copay
In-network

Occupational therapy

$40 copay
In-network

Lab services

$0 copay
In-network

Outpatient X-rays

$25 copay
In-network

Diagnostic tests and procedures, non-radiological (such as EKG/ECG tests, etc.)

$50 copay
In-network

Diagnostic radiology services (such as MRIs, CT scans, etc.)

$250 copay
In-network

Diabetes monitoring supplies

$0 copay for covered brands
In-network

Home health care

$0 copay
In-network

Urgent care

$55 copay per visit ($0 copay when outside of the United States)

Emergency care

$125 copay per visit ($0 copay when outside of the United States)

Ambulance services

$290 copay for ground or air

Dental coverage

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

Routine dental

$0 copay for covered network preventive services such as oral exams, routine cleanings, X-rays, and fluoride
You will have access to one of Medicare Advantage's largest dental networks, or you can choose any dentist. Seeing a network dentist may save you money.

Platinum Dental Rider

add $54 to your monthly premium.


$1,500 per year for covered dental services through the Platinum Dental Rider.

$0 copay for covered network preventive services such as oral exams, routine cleanings, X-rays and fluoride

50% coinsurance for bridges and dentures, $0 copay for all other covered network comprehensive services such as fillings, crowns, root canals and extractions

You will have access to one of Medicare Advantage's largest dental networks, or you can choose any dentist. Seeing a network dentist may save you money.

Extra benefits and programs

See more of the benefits and programs offered by this plan that are not provided under Original Medicare.

See the UnitedHealthcare plan difference

Routine eye exam

$0 copay 1 per year
In-network

Routine eyewear

Plan pays up to $200 every two years for 1 pair of 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).

Hearing sounds better with more access

Routine hearing exam

$0 copay 1 per year
In-network

Hearing aids

Copays from $99 - $1,249 for a broad selection of OTC and brand-name prescription hearing aids through UnitedHealthcare Hearing, up to 2 hearing aids every year

Get more for your everyday needs

OTC credit

$40 credit per quarter to buy covered OTC products.

Rewards

Earn up to $155 in rewards every year for getting an annual wellness visit, being physically active, connecting with others and more.

Fitness program

$0 copay for Renew Active®, which includes a free membership at core and premium gyms, plus online fitness classes and brain health challenges.

Routine foot care

$40 copay 6 visits per year
In-network

Meal benefit

$0 copay for 28 home-delivered meals immediately after an inpatient hospitalization or skilled nursing facility (SNF) stay.

Plan documents

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

Language

General Plan Information

Medical Providers

General Plan Information

Footnotes & disclaimers

footnote
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.

 

Featured Benefits

- 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.

 

- 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.

 

- 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.

 

Other Languages:

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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