UHC Dual Complete AR-S001 (PPO D-SNP) H0271-023 2024 Plan Details and Costs (2024)

UHC Dual Complete AR-S001 (PPO D-SNP) H0271-023 Plan Details

4 out of 5 stars

UHC Dual Complete AR-S001 (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H0271-023

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Monthly Premium

Arkansas Counties Served

Lee Phillips Hempstead Columbia Sevier Clay Scott Pike Pulaski Stone Cleveland Jackson Crawford Van Buren Mccurtain Hot Spring Faulkner Woodruff Poinsett Prairie Perry Washington Lawrence Cleburne Randolph Craighead Lafayette Ashley Calhoun Baxter Le Flore Dallas Madison Ouachita Grant Chicot Johnson Searcy Union Bradley Greene Little River Crittenden Fulton Desha Izard Howard Newton Pope Logan Cross Saline Montgomery Boone Independence White Nevada Sharp Carroll Drew Jefferson Conway Franklin Sebastian Garland Arkansas Yell Benton Saint Francis Monroe Mississippi Lonoke Clark Polk Miller

Basic Costs and Coverage

Coverage	Cost
Monthly Deductible	$0
Out of Pocket Max	In-Network: $8850 Out-of-Network: N/A
Initial Coverage Limit	$5030
Catastrophic Coverage Limit	$8,000
Primary Care Doctor Visit	In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 Out-of-Network: Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 30%
Specialty Doctor Visit	In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 Prior Authorization Required for Doctor Specialty Visit Prior authorization required Out-of-Network: Doctor Specialty Visit: Coinsurance for Medicare Covered Physician Specialist Office Visit 30%
Inpatient Hospital Care	In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0.00 Your plan covers an unlimited number of days for an inpatient stay. Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: Copayment for Acute Hospital Services per Stay $0.00
Urgent Care	Copayment for Urgent Care $0.00 Benefit Details - General 4b Note - NOTE ON COST SHARING RANGE FOR URGENTLY NEEDED SERVICES: $0 copayment applies to Medicare covered telehealth. The higher cost share applies to all other Medicare covered services. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0.00
Emergency Room Visit	Copayment for Emergency Care $0.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0.00 Copayment for Worldwide Emergency Transportation $0.00
Ambulance Transportation	In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0.00 Air Ambulance: Copayment for Air Ambulance Services $0.00 Benefit Details - General 10a Note - NOTE ON AUTHORIZATION: Authorization is required for Non-emergency Medicare-covered ambulance ground and air transportation. Emergency Ambulance does not require authorization. Please see Evidence of Coverage for Prior Authorization rules Prior authorization required Out-of-Network: Ambulance Services: Coinsurance for Medicare Covered Ambulance Services - Ground 20% Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

UHC Dual Complete AR-S001 (PPO D-SNP) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage	Cost
Chiropractic Services	In-Network: Copayment for Medicare-covered Chiropractic Services $0.00 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Chiropractic Services 30%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring	In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Diabetic Supplies and Services 30%
Durable Medical Eqipment (DME)	In-Network: Copayment for Medicare-covered Durable Medical Equipment $0.00 Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Durable Medical Equipment 30%
Diagnostic Tests, Lab and Radiology Services, and X-Rays	In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 Copayment for Medicare-covered Therapeutic Radiological Services $0.00 Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30% Copayment for Medicare Covered Lab Services $0.00 Coinsurance for Medicare Covered Diagnostic Radiological Services 30% Coinsurance for Medicare Covered Therapeutic Radiological Services 30% Coinsurance for Medicare Covered Outpatient X-Ray Services 30%
Home Health Care	In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Home Health 30%
Mental Health Inpatient Care	In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0.00 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Copayment for Psychiatric Hospital Services per Stay $0.00
Mental Health Outpatient Care	In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Mental Health Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Individual Sessions 30% Coinsurance for Medicare Covered Group Sessions 30%
Outpatient Services / Surgery	In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 30% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30%
Outpatient Substance Abuse Care	In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Individual or Group Sessions 30%
Over-the-counter (OTC) Items	In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $188.00 every month Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit Out-of-Network: Over-The-Counter (OTC) Items: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $188.00
Podiatry Services	In-Network: Copayment for Medicare-Covered Podiatry Services $0.00 Copayment for Routine Foot Care $0.00 Maximum 6 visits every year Prior Authorization Required for Podiatry Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Podiatry Services 30% Copayment for Non-Medicare Covered Podiatry Services $0.00
Skilled Nursing Facility Care	In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $0.00 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: Copayment for Skilled Nursing Facility Services per Stay $0.00

Dental Benefits

The following dental services are covered from in-network providers.

Coverage	Cost
Dental Care	In-Network: Preventive Dental: Copayment for Oral Exams $0.00 Maximum 2 visits every year Copayment for Prophylaxis (Cleaning) $0.00 Maximum 3 visits every year Copayment for Fluoride Treatment $0.00 Maximum 2 visits every year Copayment for Dental X-Rays $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $2500.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 Copayment for Non-routine Services $0.00 Copayment for Diagnostic Services $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Copayment for Restorative Services $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Copayment for Endodontics $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Copayment for Periodontics $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Copayment for Extractions $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $2500.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined Prior Authorization Required for Comprehensive Dental Prior authorization required Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 30% Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Preventive Dental $0.00 Copayment for Non-Medicare Covered Comprehensive Dental $0.00

Coverage

Cost

Dental Care

In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00

Maximum 2 visits every year

Copayment for Prophylaxis (Cleaning) $0.00

Maximum 3 visits every year

Copayment for Fluoride Treatment $0.00

Maximum 2 visits every year

Copayment for Dental X-Rays $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Maximum Plan Benefit of $2500.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Copayment for Non-routine Services $0.00
Copayment for Diagnostic Services $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Restorative Services $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Endodontics $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Periodontics $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Extractions $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Maximum Plan Benefit of $2500.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined
Prior Authorization Required for Comprehensive Dental
Prior authorization required

Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 30%
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $0.00
Copayment for Non-Medicare Covered Comprehensive Dental $0.00

Vision Benefits

The following vision services are covered from in-network providers.

Coverage	Cost
Vision Benefits	In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Eye Exams $0.00 Maximum 1 Routine Eye Exam every year Prior Authorization Required for Eye Exams Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00 Copayment for Eyeglasses (lenses and frames) $0.00 Maximum 1 Pair every year Maximum Plan Benefit of $200.00 every year for all Non-Medicare covered eyewear for in and out of network services combined Prior authorization required Out-of-Network: Medicare Covered Vision Services: Coinsurance for Medicare Covered Eye Exams 30% Coinsurance for Medicare Covered Eyewear 30% Non-Medicare Covered Vision Services: Coinsurance for Non-Medicare Covered Eye Exams 30% Copayment for Non-Medicare Covered Eyewear $0.00

Coverage

Cost

Vision Benefits

In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Eye Exams $0.00

Maximum 1 Routine Eye Exam every year

Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
Copayment for Eyeglasses (lenses and frames) $0.00

Maximum 1 Pair every year

Maximum Plan Benefit of $200.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Prior authorization required

Out-of-Network:

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 30%
Coinsurance for Medicare Covered Eyewear 30%
Non-Medicare Covered Vision Services:
Coinsurance for Non-Medicare Covered Eye Exams 30%
Copayment for Non-Medicare Covered Eyewear $0.00

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage	Cost
Hearing Benefits	In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Hearing Exams $0.00 Maximum 1 visit every year Prior Authorization Required for Hearing Exams Hearing Aids: Maximum Plan Allowance of $2500.00 every year both ears combined for in and out of network services combined Prior Authorization Required for Hearing Aids Prior authorization required Out-of-Network: Medicare Covered Hearing Services: Coinsurance for Medicare Covered Hearing Exams 30% Non-Medicare Covered Hearing Services: Coinsurance for Non-Medicare Covered Hearing Exams 30% Copayment for Non-Medicare Covered Hearing Aids $0.00

Coverage

Cost

Hearing Benefits

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00

Maximum 1 visit every year

Prior Authorization Required for Hearing Exams

Hearing Aids:
Maximum Plan Allowance of $2500.00 every year both ears combined for in and out of network services combined
Prior Authorization Required for Hearing Aids
Prior authorization required

Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 30%
Non-Medicare Covered Hearing Services:
Coinsurance for Non-Medicare Covered Hearing Exams 30%
Copayment for Non-Medicare Covered Hearing Aids $0.00

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage	Cost
Preventive Services and Health/Wellness Education Programs	In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginl cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots: COVID-19 shots Flu shots Hepatitis B shots Pneumococcal shots Tobacco use cessation Yearly "Wellness" visit Out-of-Network:* Medicare-covered Zero Dollar Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 30%

Coverage

Cost

Preventive Services and Health/Wellness Education Programs

In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vagin*l cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

COVID-19 shots

Flu shots

Hepatitis B shots

Pneumococcal shots

Tobacco use cessation
Yearly "Wellness" visit

Out-of-Network:

Medicare-covered Zero Dollar Preventive Services:
Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 30%

Prescription Drug Costs and Coverage

The UHC Dual Complete AR-S001 (PPO D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $0 per year.

Coverage	Cost
Coverage & Cost
Annual Drug Deductible	$0
Preferred Generic	Standard retail $0.00 Preferred cost-share mail order N/A Standard mail order N/A
Generic	Standard retail $0.00 Preferred cost-share mail order N/A Standard mail order N/A
Preferred Brand	Standard retail $0.00 Preferred cost-share mail order N/A Standard mail order N/A
Non-Preferred Drug	Standard retail $0.00 Preferred cost-share mail order N/A Standard mail order N/A
Specialty Tier	Standard retail $0.00 Preferred cost-share mail order $0.00 Standard mail order $0.00
Annual Drug Deductible	$0
Preferred Generic	Standard retail N/A Preferred cost-share mail order N/A Standard mail order N/A
Generic	Standard retail N/A Preferred cost-share mail order N/A Standard mail order N/A
Preferred Brand	Standard retail N/A Preferred cost-share mail order N/A Standard mail order N/A
Non-Preferred Drug	Standard retail N/A Preferred cost-share mail order N/A Standard mail order N/A
Specialty Tier	Standard retail N/A Preferred cost-share mail order N/A Standard mail order N/A
Annual Drug Deductible	$0
Preferred Generic	Standard retail $0.00 Preferred cost-share mail order $0.00 Standard mail order $0.00
Generic	Standard retail $0.00 Preferred cost-share mail order $0.00 Standard mail order $0.00
Preferred Brand	Standard retail $0.00 Preferred cost-share mail order $0.00 Standard mail order $0.00
Non-Preferred Drug	Standard retail $0.00 Preferred cost-share mail order $0.00 Standard mail order $0.00
Specialty Tier	Standard retail N/A Preferred cost-share mail order N/A Standard mail order N/A

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