United Healthcare Physical Therapy Copay

2021 Medicare Advantage Plan Details
Medicare Plan Name:	UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
Location:	Schuyler, New York
Plan ID:	R5342 - 001 - 0 Click to see other plans
Member Services:	1-800-711-6088 TTY users 711
— Enrollment Options —
Medicare Contact Information:	1-800-MEDICARE (1-800-633-4227) TTY users 1-877-486-2048
Medicare plan advice at no cost from licensed insurance agents. Call: 888-205-9813 / TTY 711 Monday‐Friday 8am — 8pm ET
Email a copy of the UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO) benefit details
— Medicare Plan Features —
Monthly Premium:	$16.00 (see Plan Premium Details below)
Annual Deductible:	$300 (Tier Yes excluded from the Deductible.)
Annual Initial Coverage Limit (ICL):	$4,130
Health Plan Type:	Regional PPO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):	$6,700
Additional Gap Coverage?	No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:	3,609 drugs	Browse the UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers.
This plan offers select insulin at $35 or less. Learn more.
Formulary Drug Details:	Tier 1	Tier 2	Tier 3	Tier 4	Tier 5
• Preferred Pharmacy Cost-Sharing during initial coverage phase:	$3.00	$12.00	$47.00	$100.00	27%
• Number of Drugs per Tier:	303	675	867	1010	754
Plan's Pharmacy Search:	http://www.UHCMedicareSolutions.com
Plan Offers Mail Order?	Yes
Number of Members enrolled in this plan in Schuyler, New York:		185 members
Number of Members enrolled in this plan in (R5342 - 001):		92,636 members
Plan’s Summary Star Rating:		4 out of 5 Stars.
• Customer Service Rating:		5 out of 5 Stars.
• Member Experience Rating:		3 out of 5 Stars.
• Drug Cost Accuracy Rating:		4 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows:❔	Total Premium	Part C Premium	Part D Base Premium	Part D Supplemental Premium
The Monthly Premium is Split as Follows:❔	$16.00	$0.00	$16.00	$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS):❔		100% Subsidy	75% Subsidy	50% Subsidy	25% Subsidy
Monthly Part D Premium with LIS:		$0.00	$4.00	$8.00	$12.00
Total Monthly Premium with LIS (Parts C & D):		$0.00	$4.00	$8.00	$12.00

United Healthcare Physical Therapy Copay Program
United Healthcare Physical Therapy Copay
United Healthcare Outpatient Physical Therapy
United Healthcare Physical Therapy Coverage

— Plan Health Benefits —
Base Plan
Premium
• Health plan premium: $0
• Drug plan premium: $16
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
• Drug plan deductible: $300.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $10,000 In and Out-of-network $6,700 In-network
Optional supplemental benefits
• Yes
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary In-network: $0 copay
• Primary Out-of-network: $50 copay per visit
• Specialist In-network: $45 copay per visit (authorization required)
• Specialist Out-of-network: $75 copay per visit (authorization required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures In-network: $30 copay (authorization required)
• Diagnostic tests and procedures Out-of-network: 40% coinsurance (authorization required)
• Lab services In-network: $0 copay (authorization required)
• Lab services Out-of-network: $0 copay (authorization required)
• Diagnostic radiology services (e.g., MRI) In-network: $0-160 copay (authorization required)
• Diagnostic radiology services (e.g., MRI) Out-of-network: 40% coinsurance (authorization required)
• Outpatient x-rays In-network: $50 copay (authorization required)
• Outpatient x-rays Out-of-network: $50 copay (authorization required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $30-40 copay per visit (always covered)
Inpatient hospital coverage
• In-network: $375 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 91 and beyond (authorization required)
• Out-of-network: $500 per day for days 1 through 20 $0 per day for days 21 and beyond (authorization required)
Outpatient hospital coverage
• In-network: $0-325 copay per visit (authorization required)
• Out-of-network: 40% coinsurance per visit (authorization required)
Skilled Nursing Facility
• In-network: $0 per day for days 1 through 20 $184 per day for days 21 through 57 $0 per day for days 58 through 100 (authorization required)
• Out-of-network: $225 per day for days 1 through 45 $0 per day for days 46 through 100 (authorization required)
Preventive care
• In-network: $0 copay
• Out-of-network: 0-40% coinsurance
Ground ambulance
• In-network: $250 copay
• Out-of-network: $250 copay
Rehabilitation services
• Occupational therapy visit In-network: $40 copay (authorization required)
• Occupational therapy visit Out-of-network: $75 copay (authorization required)
• Physical therapy and speech and language therapy visit In-network: $40 copay (authorization required)
• Physical therapy and speech and language therapy visit Out-of-network: $75 copay (authorization required)
Mental health services
• Inpatient hospital - psychiatric In-network: $375 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required)
• Inpatient hospital - psychiatric Out-of-network: $500 per day for days 1 through 20 $0 per day for days 21 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist In-network: $15 copay (authorization required)
• Outpatient group therapy visit with a psychiatrist Out-of-network: $30-40 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist In-network: $25 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist Out-of-network: $30-40 copay (authorization required)
• Outpatient group therapy visit In-network: $15 copay (authorization required)
• Outpatient group therapy visit Out-of-network: $30-40 copay (authorization required)
• Outpatient individual therapy visit In-network: $25 copay (authorization required)
• Outpatient individual therapy visit Out-of-network: $30-40 copay (authorization required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 20% coinsurance per item (authorization required)
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 50% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) In-network: 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) Out-of-network: 40% coinsurance per item (authorization required)
• Diabetes supplies In-network: $0 copay per item (authorization required)
• Diabetes supplies Out-of-network: 40% coinsurance per item (authorization required)
Hearing
• Hearing exam In-network: $0 copay (authorization required)
• Hearing exam Out-of-network: $75 copay (authorization required)
• Fitting/evaluation: Not covered
• Hearing aids In-network: $375-2,075 copay (limits apply, authorization required)
• Hearing aids Out-of-network: $375 copay (limits apply, authorization required)
Preventive dental
• Oral exam In-network: $0 copay (limits apply)
• Oral exam Out-of-network: $0 copay (limits apply)
• Cleaning In-network: $0 copay (limits apply)
• Cleaning Out-of-network: $0 copay (limits apply)
• Fluoride treatment In-network: $0 copay (limits apply)
• Fluoride treatment Out-of-network: $0 copay (limits apply)
• Dental x-ray(s) In-network: $0 copay (limits apply)
• Dental x-ray(s) Out-of-network: $0 copay (limits apply)
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services: Not covered
• Restorative services: Not covered
• Endodontics: Not covered
• Periodontics: Not covered
• Extractions: Not covered
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
Vision
• Routine eye exam In-network: $0 copay (limits apply, authorization required)
• Routine eye exam Out-of-network: $75 copay (limits apply, authorization required)
• Other: Not covered
• Contact lenses In-network: $0 copay (limits apply)
• Contact lenses Out-of-network: $0 copay (limits apply)
• Eyeglasses (frames and lenses) In-network: $0 copay (limits apply)
• Eyeglasses (frames and lenses) Out-of-network: $0 copay (limits apply)
• Eyeglass frames: Not covered
• Eyeglass lenses: Not covered
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• Not covered
Foot care (podiatry services)
• Foot exams and treatment In-network: $45 copay (authorization required)
• Foot exams and treatment Out-of-network: $75 copay (authorization required)
• Routine foot care In-network: $45 copay (limits apply, authorization required)
• Routine foot care Out-of-network: $75 copay (limits apply, authorization required)
Medicare Part B drugs
• Chemotherapy In-network: 20% coinsurance (authorization required)
• Chemotherapy Out-of-network: 40% coinsurance (authorization required)
• Other Part B drugs In-network: 20% coinsurance (authorization required)
• Other Part B drugs Out-of-network: 40% coinsurance (authorization required)
Package #1
• Monthly Premium: $40.00
• Deductible:

Get cost estimates before choosing care. You may pay up to 36% less 1. Checking cost estimates before you choose where to get care can be an effective way to save on health care costs. In fact, it’s been shown that people who look at costs first may pay up to 36% less for their care. So, it can be worthwhile.
Limitations, copays and restrictions may apply. For more information, call UnitedHealthcare Connected Member Services or read the UnitedHealthcare Connected Member Handbook. Benefits and/or copayments may change on January 1 of each year. UnitedHealthcare Senior.

2021 Medicare Advantage Plan Details
Medicare Plan Name:	UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
Location:	Schuyler, New York
Plan ID:	R5342 - 001 - 0 Click to see other plans
Member Services:	1-800-711-6088 TTY users 711
— Enrollment Options —
Medicare Contact Information:	1-800-MEDICARE (1-800-633-4227) TTY users 1-877-486-2048
Medicare plan advice at no cost from licensed insurance agents. Call: 888-205-9813 / TTY 711 Monday‐Friday 8am — 8pm ET
Email a copy of the UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO) benefit details
— Medicare Plan Features —
Monthly Premium:	$16.00 (see Plan Premium Details below)
Annual Deductible:	$300 (Tier Yes excluded from the Deductible.)
Annual Initial Coverage Limit (ICL):	$4,130
Health Plan Type:	Regional PPO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):	$6,700
Additional Gap Coverage?	No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:	3,609 drugs	Browse the UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers.
This plan offers select insulin at $35 or less. Learn more.
Formulary Drug Details:	Tier 1	Tier 2	Tier 3	Tier 4	Tier 5
• Preferred Pharmacy Cost-Sharing during initial coverage phase:	$3.00	$12.00	$47.00	$100.00	27%
• Number of Drugs per Tier:	303	675	867	1010	754
Plan's Pharmacy Search:	http://www.UHCMedicareSolutions.com
Plan Offers Mail Order?	Yes
Number of Members enrolled in this plan in Schuyler, New York:		185 members
Number of Members enrolled in this plan in (R5342 - 001):		92,636 members
Plan’s Summary Star Rating:		4 out of 5 Stars.
• Customer Service Rating:		5 out of 5 Stars.
• Member Experience Rating:		3 out of 5 Stars.
• Drug Cost Accuracy Rating:		4 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows:❔	Total Premium	Part C Premium	Part D Base Premium	Part D Supplemental Premium
The Monthly Premium is Split as Follows:❔	$16.00	$0.00	$16.00	$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS):❔		100% Subsidy	75% Subsidy	50% Subsidy	25% Subsidy
Monthly Part D Premium with LIS:		$0.00	$4.00	$8.00	$12.00
Total Monthly Premium with LIS (Parts C & D):		$0.00	$4.00	$8.00	$12.00

United Healthcare Physical Therapy Copay Program

United Healthcare Physical Therapy Copay

— Plan Health Benefits —
Base Plan
Premium
• Health plan premium: $0
• Drug plan premium: $16
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
• Drug plan deductible: $300.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $10,000 In and Out-of-network $6,700 In-network
Optional supplemental benefits
• Yes
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary In-network: $0 copay
• Primary Out-of-network: $50 copay per visit
• Specialist In-network: $45 copay per visit (authorization required)
• Specialist Out-of-network: $75 copay per visit (authorization required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures In-network: $30 copay (authorization required)
• Diagnostic tests and procedures Out-of-network: 40% coinsurance (authorization required)
• Lab services In-network: $0 copay (authorization required)
• Lab services Out-of-network: $0 copay (authorization required)
• Diagnostic radiology services (e.g., MRI) In-network: $0-160 copay (authorization required)
• Diagnostic radiology services (e.g., MRI) Out-of-network: 40% coinsurance (authorization required)
• Outpatient x-rays In-network: $50 copay (authorization required)
• Outpatient x-rays Out-of-network: $50 copay (authorization required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $30-40 copay per visit (always covered)
Inpatient hospital coverage
• In-network: $375 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 91 and beyond (authorization required)
• Out-of-network: $500 per day for days 1 through 20 $0 per day for days 21 and beyond (authorization required)
Outpatient hospital coverage
• In-network: $0-325 copay per visit (authorization required)
• Out-of-network: 40% coinsurance per visit (authorization required)
Skilled Nursing Facility
• In-network: $0 per day for days 1 through 20 $184 per day for days 21 through 57 $0 per day for days 58 through 100 (authorization required)
• Out-of-network: $225 per day for days 1 through 45 $0 per day for days 46 through 100 (authorization required)
Preventive care
• In-network: $0 copay
• Out-of-network: 0-40% coinsurance
Ground ambulance
• In-network: $250 copay
• Out-of-network: $250 copay
Rehabilitation services
• Occupational therapy visit In-network: $40 copay (authorization required)
• Occupational therapy visit Out-of-network: $75 copay (authorization required)
• Physical therapy and speech and language therapy visit In-network: $40 copay (authorization required)
• Physical therapy and speech and language therapy visit Out-of-network: $75 copay (authorization required)
Mental health services
• Inpatient hospital - psychiatric In-network: $375 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required)
• Inpatient hospital - psychiatric Out-of-network: $500 per day for days 1 through 20 $0 per day for days 21 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist In-network: $15 copay (authorization required)
• Outpatient group therapy visit with a psychiatrist Out-of-network: $30-40 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist In-network: $25 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist Out-of-network: $30-40 copay (authorization required)
• Outpatient group therapy visit In-network: $15 copay (authorization required)
• Outpatient group therapy visit Out-of-network: $30-40 copay (authorization required)
• Outpatient individual therapy visit In-network: $25 copay (authorization required)
• Outpatient individual therapy visit Out-of-network: $30-40 copay (authorization required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 20% coinsurance per item (authorization required)
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 50% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) In-network: 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) Out-of-network: 40% coinsurance per item (authorization required)
• Diabetes supplies In-network: $0 copay per item (authorization required)
• Diabetes supplies Out-of-network: 40% coinsurance per item (authorization required)
Hearing
• Hearing exam In-network: $0 copay (authorization required)
• Hearing exam Out-of-network: $75 copay (authorization required)
• Fitting/evaluation: Not covered
• Hearing aids In-network: $375-2,075 copay (limits apply, authorization required)
• Hearing aids Out-of-network: $375 copay (limits apply, authorization required)
Preventive dental
• Oral exam In-network: $0 copay (limits apply)
• Oral exam Out-of-network: $0 copay (limits apply)
• Cleaning In-network: $0 copay (limits apply)
• Cleaning Out-of-network: $0 copay (limits apply)
• Fluoride treatment In-network: $0 copay (limits apply)
• Fluoride treatment Out-of-network: $0 copay (limits apply)
• Dental x-ray(s) In-network: $0 copay (limits apply)
• Dental x-ray(s) Out-of-network: $0 copay (limits apply)
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services: Not covered
• Restorative services: Not covered
• Endodontics: Not covered
• Periodontics: Not covered
• Extractions: Not covered
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
Vision
• Routine eye exam In-network: $0 copay (limits apply, authorization required)
• Routine eye exam Out-of-network: $75 copay (limits apply, authorization required)
• Other: Not covered
• Contact lenses In-network: $0 copay (limits apply)
• Contact lenses Out-of-network: $0 copay (limits apply)
• Eyeglasses (frames and lenses) In-network: $0 copay (limits apply)
• Eyeglasses (frames and lenses) Out-of-network: $0 copay (limits apply)
• Eyeglass frames: Not covered
• Eyeglass lenses: Not covered
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• Not covered
Foot care (podiatry services)
• Foot exams and treatment In-network: $45 copay (authorization required)
• Foot exams and treatment Out-of-network: $75 copay (authorization required)
• Routine foot care In-network: $45 copay (limits apply, authorization required)
• Routine foot care Out-of-network: $75 copay (limits apply, authorization required)
Medicare Part B drugs
• Chemotherapy In-network: 20% coinsurance (authorization required)
• Chemotherapy Out-of-network: 40% coinsurance (authorization required)
• Other Part B drugs In-network: 20% coinsurance (authorization required)
• Other Part B drugs Out-of-network: 40% coinsurance (authorization required)
Package #1
• Monthly Premium: $40.00
• Deductible:

United Healthcare Outpatient Physical Therapy

United Healthcare Physical Therapy Coverage

. Occupational therapy visit: $15 copay (authorization and referral required). Physical therapy and speech and language therapy visit: $15 copay (authorization and referral required) Mental health services. Inpatient hospital - psychiatric: $100 per day for days 1 through 7.