UHC Nursing Home Plan EX-F003 (PPO I-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H0710-026
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$33.50
Monthly Premium
UHC Nursing Home Plan EX-F003 (PPO I-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H0710-026
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Get Medicare Help
UHC Nursing Home Plan EX-F003 (PPO I-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: H0710-026
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Get Medicare Help
$33.50
Monthly Premium
Maine Counties Served
Oxford Penobscot Kennebec York Cumberland Franklin Somerset
New Hampshire Counties Served
Coos Hillsborough Rockingham Cheshire Belknap Oxford Carroll Sullivan Grafton Merrimack
New Jersey Counties Served
Mercer Burlington Camden Atlantic Gloucester Cumberland Cape May Monmouth Union Morris Somerset Bergen Sussex Hudson Essex Passaic Middlesex Ocean Warren
Connecticut Counties Served
Litchfield Windham Hartford Fairfield New Haven Tolland New London Middlesex
Basic Costs and Coverage
Coverage | Cost |
---|---|
Monthly Deductible | $545 |
Out of Pocket Max | In-Network: $2300 Out-of-Network: N/A |
Initial Coverage Limit | $5030 |
Catastrophic Coverage Limit | $8,000 |
Primary Care Doctor Visit | In-Network: Doctor Office Visit: Out-of-Network: Doctor Office Visit: |
Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Out-of-Network: Doctor Specialty Visit: |
Inpatient Hospital Care | In-Network: Acute Hospital Services: Out-of-Network: |
Urgent Care | Copayment for Urgent Care $0.00 to $40.00 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. |
Emergency Room Visit | Copayment for Emergency Care $100.00 |
Ambulance Transportation | In-Network: Ground Ambulance: Air Ambulance: 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. Out-of-Network: Ambulance Services: |
Health Care Services and Medical Supplies
UHC Nursing Home Plan EX-F003 (PPO I-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: Out-of-Network: |
Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Out-of-Network: |
Durable Medical Eqipment (DME) | In-Network: Out-of-Network: |
Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Outpatient Diag/Therapeutic Rad Services: Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: |
Home Health Care | In-Network: Out-of-Network: |
Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Out-of-Network: |
Mental Health Outpatient Care | In-Network: Out-of-Network: |
Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Outpatient Observation Services: Ambulatory Surgical Center Services: Out-of-Network: Outpatient Hospital and ASC Services: |
Outpatient Substance Abuse Care | In-Network: Out-of-Network: |
Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Out-of-Network: Over-The-Counter (OTC) Items: |
Podiatry Services | In-Network:
Prior Authorization Required for Podiatry Services Out-of-Network: |
Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: Out-of-Network: |
Dental Benefits
The following dental services are covered from in-network providers.
Coverage | Cost |
---|---|
Dental Care | In-Network: Preventive Dental:
Copayment for Prophylaxis (Cleaning) $0.00
Copayment for Fluoride Treatment $0.00
Copayment for Dental X-Rays $0.00
Maximum Plan Benefit of $3250.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined Comprehensive Dental:
Copayment for Diagnostic Services $0.00
Copayment for Restorative Services $0.00
Copayment for Endodontics $0.00
Copayment for Periodontics $0.00
Copayment for Extractions $0.00
Maximum Plan Benefit of $3250.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined Out-of-Network: Medicare Covered Dental Services: |
Vision Benefits
The following vision services are covered from in-network providers.
Coverage | Cost |
---|---|
Vision Benefits | In-Network: Eye Exams:
Prior Authorization Required for Eye Exams Eyewear:
Maximum Plan Benefit of $300.00 every year for all Non-Medicare covered eyewear for in and out of network services combined Out-of-Network: Medicare Covered Vision Services: |
Hearing Benefits
The following hearing services are covered from in-network providers.
Coverage | Cost |
---|---|
Hearing Benefits | In-Network: Hearing Exams:
Prior Authorization Required for Hearing Exams Hearing Aids:
Maximum Plan Benefit of $2000.00 every year both ears combined for in and out of network services combined Out-of-Network: Medicare Covered Hearing Services: |
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: Abdominal aortic aneurysm screening
Tobacco use cessation Out-of-Network: Medicare-covered Zero Dollar Preventive Services: |
Prescription Drug Costs and Coverage
The UHC Nursing Home Plan EX-F003 (PPO I-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $545 (excludes Tiers 1 and 2) per year.
Coverage | Cost |
---|---|
Coverage & Cost | |
Annual Drug Deductible | $545 (excludes Tiers 1 and 2) |
Preferred Generic |
|
Generic |
|
Annual Drug Deductible | $545 (excludes Tiers 1 and 2) |
Preferred Generic |
|
Generic |
|
Annual Drug Deductible | $545 (excludes Tiers 1 and 2) |
Preferred Generic |
|
Generic |
|
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