UHC Dual Complete WA-D001 (PPO D-SNP) H0271-044-000 2024 Plan Details and Costs (2024)

Basic Costs and Coverage

Coverage	Details
Monthly plan premium	$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$0.00
Out-of-pocket maximum	$8,850.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$8,000.00
Primary care doctor visit	In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00
Specialty doctor visit	In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 Prior Authorization Required for Doctor Specialty Visit
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
Urgent care	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	Emergency Care: 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

Health Care Services and Medical Supplies

UHC Dual Complete WA-D001 (PPO D-SNP) covers a range of additional benefits. Learn more about UHC Dual Complete WA-D001 (PPO D-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage	Details
Chiropractic services	Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 30% Chiropractic Services: Coinsurance for Non-Medicare Covered Chiropractic Services 30%
Diabetes supplies, training, nutrition therapy and monitoring	In-Network: Diabetic Supplies and Services: 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)
Durable medical equipment (DME)	Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 30%
Diagnostic tests, lab and radiology services, and X-rays	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: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services
Mental health inpatient care	Out-of-Network: Copayment for Psychiatric Hospital Services per Stay $0.00
Mental health outpatient care	In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Mental Health Services
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
Outpatient substance abuse care	Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual or Group Sessions 30%
Over-the-counter items	In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $159.00 every month Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry services	In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $0.00 Copayment for Routine Foot Care $0.00 Maximum 4 visits every year Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) care	Out-of-Network: Copayment for Skilled Nursing Facility Services per Stay $0.00

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
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 $3000.00 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 $3000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined Prior Authorization Required for Comprehensive Dental

Coverage

Details

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 $3000.00 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 $3000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined
Prior Authorization Required for Comprehensive Dental

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
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 $300.00 every year for all Non-Medicare covered eyewear for in and out of network services combined

Coverage

Details

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 $300.00 every year for all Non-Medicare covered eyewear for in and out of network services combined

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
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: Copayment for Hearing Aids $0.00 Maximum 2 Hearing Aids every year Maximum Plan Benefit of $1100.00 every year both ears combined for in and out of network services combined Prior Authorization Required for Hearing Aids

Coverage

Details

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:
Copayment for Hearing Aids $0.00

Maximum 2 Hearing Aids every year

Maximum Plan Benefit of $1100.00 every year both ears combined for in and out of network services combined
Prior Authorization Required for Hearing Aids

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Preventive services and health/wellness education programs	Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 30%

When reviewing Washington Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Washington that offer similar benefits at similar or lower prices than the plan above. Call 1-855-580-1854 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Summary of benefits
Evidence of coverage
Star ratings

Washington Counties Served

Asotin Benewah Benton Clark Columbia Cowlitz Douglas Franklin Garfield Island Jefferson King Kitsap Kittitas Lewis Lincoln Mason Pacific Pend Oreille Pierce San Juan Skagit Snohomish Spokane Thurston Umatilla Wahkiakum Walla Walla Whatcom Whitman Yakima

We represent carriers such as Humana, UnitedHealthcare^®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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