Go Back
H0271 - 016 - 0
(4 / 5)
UnitedHealthcare Dual Complete (PPO D-SNP)is a Medicare Advantage (Part C) Special Needs Plan by UnitedHealthcare.
This page features plan details for 2022 UnitedHealthcare Dual Complete (PPO D-SNP)H0271 – 016 – 0 available in Select counties in South Carolina.
IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:
2024 UHC Dual Complete SC-S001 (PPO D-SNP) H0271 - 016 - 0
Locations
UnitedHealthcare Dual Complete (PPO D-SNP)is offered in the following locations.
Abbeville County, South Carolina
South Carolina
Click to see more locations
Plan Overview
UnitedHealthcare Dual Complete (PPO D-SNP)offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Dual-Eligible |
| Conditions Covered: |
| Insurer: | UnitedHealthcare |
| Health Plan Deductible: | $0 |
| MOOP: | $7,550 In and Out-of-network $7,550 In-network |
| Drugs Covered: | Yes |
Please Note:
- This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.
- Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.
Ready to sign up for UnitedHealthcare Dual Complete (PPO D-SNP)?
Get help from a licensed insurance agent.
Call 1-877-354-4611 TTY 711.
8am – 11pm EST. 7 days a week
Premium Breakdown
UnitedHealthcare Dual Complete (PPO D-SNP)has a monthly premium of $0. This amount includes your Part C and D premiums but does not include your Part B premium.The following is a breakdown of your monthly premium with Part B costs included.
| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $170.10 | $0.00 | $0.00 | $0.00 | $170.10 |
Please Note:
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
UnitedHealthcare Dual Complete (PPO D-SNP)provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $480.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Basic |
| Gap Coverage: | No Gap Coverage |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.The table below shows how the LIS impacts the Part D premium of this plan.
| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $0.00 | $23.30 | $15.50 | $7.80 | $0.00 |
Initial Coverage Phase
After you pay your $480.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
30 Day
90 Day
30 Day
90 Day
| Drug Type | Cost Share |
|---|---|
| Generic drugs | 25% |
| Brand-name drugs | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
UnitedHealthcare Dual Complete (PPO D-SNP)also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | In-Network: $0 copay (limits may apply) (authorization required) |
| Diagnostic services: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
| Endodontics: | In-Network: $0 copay (limits may apply) (authorization required) |
| Endodontics: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
| Extractions: | In-Network: $0 copay (limits may apply) (authorization required) |
| Extractions: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
| Non-routine services: | In-Network: $0 copay (limits may apply) (authorization required) |
| Non-routine services: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
| Periodontics: | In-Network: $0 copay (limits may apply) (authorization required) |
| Periodontics: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | In-Network: $0 copay (limits may apply) (authorization required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
| Restorative services: | In-Network: $0 copay (limits may apply) (authorization required) |
| Restorative services: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
Dental (preventive)
| Cleaning: | In-Network: $0 copay (limits may apply) |
| Cleaning: | Out-of-Network: $0 copay (limits may apply) |
| Dental x-ray(s): | In-Network: $0 copay (limits may apply) |
| Dental x-ray(s): | Out-of-Network: $0 copay (limits may apply) |
| Fluoride treatment: | In-Network: $0 copay (limits may apply) |
| Fluoride treatment: | Out-of-Network: $0 copay (limits may apply) |
| Oral exam: | In-Network: $0 copay (limits may apply) |
| Oral exam: | Out-of-Network: $0 copay (limits may apply) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | In-Network: $0 copay (authorization required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: 0-20% coinsurance (authorization required) |
| Diagnostic tests and procedures: | In-Network: $0 copay (authorization required) |
| Diagnostic tests and procedures: | Out-of-Network: 20% coinsurance (authorization required) |
| Lab services: | In-Network: $0 copay (authorization required) |
| Lab services: | Out-of-Network: $0 copay (authorization required) |
| Outpatient x-rays: | In-Network: $0 copay (authorization required) |
| Outpatient x-rays: | Out-of-Network: 20% coinsurance (authorization required) |
Doctor visits
| Primary: | In-Network: $0 copay |
| Primary: | Out-of-Network: 20% coinsurance per visit |
| Specialist: | In-Network: $0 copay (authorization required) |
| Specialist: | Out-of-Network: 20% coinsurance per visit (authorization required) |
Emergency care/Urgent care
| Emergency: | $0 copay |
| Urgent care: | $0 copay |
Foot care (podiatry services)
| Foot exams and treatment: | In-Network: $0 copay (authorization required) |
| Foot exams and treatment: | Out-of-Network: 20% coinsurance (authorization required) |
| Routine foot care: | In-Network: $0 copay (limits may apply) (authorization required) |
| Routine foot care: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
Ground ambulance
| In-Network: $0 copay | |
| Out-of-Network: 20% coinsurance |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | Not covered |
| Hearing aids: | In-Network: $0 copay (limits may apply) (authorization required) |
| Hearing aids: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
| Hearing exam: | In-Network: $0 copay (authorization required) |
| Hearing exam: | Out-of-Network: 20% coinsurance (authorization required) |
Hospital coverage (inpatient)
| In-Network: $0 copay (authorization required) | |
| Out-of-Network: 20% per stay (authorization required) |
Hospital coverage (outpatient)
| In-Network: $0 copay (authorization required) | |
| Out-of-Network: 0-20% coinsurance per visit (authorization required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $7,550 In and Out-of-network $7,550 In-network |
Medical equipment/supplies
| Diabetes supplies: | In-Network: $0 copay (authorization required) |
| Diabetes supplies: | Out-of-Network: 20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: $0 copay (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | In-Network: $0 copay (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | In-Network: $0 copay (authorization required) |
| Chemotherapy: | Out-of-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: $0 copay (authorization required) |
| Other Part B drugs: | Out-of-Network: 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | In-Network: $0 copay (authorization required) |
| Inpatient hospital – psychiatric: | Out-of-Network: 20% per stay (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $0 copay (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: $0 copay (authorization required) |
| Outpatient group therapy visit: | In-Network: $0 copay (authorization required) |
| Outpatient group therapy visit: | Out-of-Network: $0 copay (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $0 copay (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: $0 copay (authorization required) |
| Outpatient individual therapy visit: | In-Network: $0 copay (authorization required) |
| Outpatient individual therapy visit: | Out-of-Network: $0 copay (authorization required) |
Optional supplemental benefits
| No |
Preventive care
| In-Network: $0 copay | |
| Out-of-Network: 0-20% coinsurance |
Rehabilitation services
| Occupational therapy visit: | In-Network: $0 copay (authorization required) |
| Occupational therapy visit: | Out-of-Network: 20% coinsurance (authorization required) |
| Physical therapy and speech and language therapy visit: | In-Network: $0 copay (authorization required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: 20% coinsurance (authorization required) |
Skilled Nursing Facility
| In-Network: $0 copay (authorization required) | |
| Out-of-Network: Contact plan for details (authorization required) |
Transportation
| In-Network: $0 copay (limits may apply) | |
| Out-of-Network: 75% coinsurance (limits may apply) |
Vision
| Contact lenses: | In-Network: $0 copay (limits may apply) |
| Contact lenses: | Out-of-Network: $0 copay (limits may apply) |
| Eyeglass frames: | Not covered |
| Eyeglass lenses: | Not covered |
| Eyeglasses (frames and lenses): | In-Network: $0 copay (limits may apply) |
| Eyeglasses (frames and lenses): | Out-of-Network: $0 copay (limits may apply) |
| Other: | Not covered |
| Routine eye exam: | In-Network: $0 copay (limits may apply) (authorization required) |
| Routine eye exam: | Out-of-Network: 20% coinsurance (limits may apply) (authorization required) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
Ready to sign up for UnitedHealthcare Dual Complete (PPO D-SNP)?
Get help from a licensed insurance agent.
Call 1-877-354-4611 TTY 711.
8am – 11pm EST. 7 days a week
