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UnitedHealthcare

Plan ID: H0271-7-0

UHC Medicare Advantage NH-001A (PPO)

2024 UHC Medicare Advantage NH-001A (PPO) H0271 — 007 — 0 is a Medicare Advantage plan with drug coverage. It has received a 4-out-of-5 star rating from CMS for 2024.

Learn more about UHC Medicare Advantage NH-001A (PPO) H0271 - 007 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

4 / 5 stars for 2024

$36.00 /mo

Monthly premium

Coming soon

Health deductible

$545.00

Drug deductible

$8850.00

Out-of-pocket maximum

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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!

Overview Benefits & Costs Drug Coverage Additional Benefits

Plan Overview

2024 UHC Medicare Advantage NH-001A (PPO) H0271 — 007 — 0 is a Local PPO offered in State of New Hampshire by UnitedHealthcare. It has a monthly premium of $36.00.

Premium Breakdown

Standard Part B Premium

$174.70

Part B premium reduction

- $0

Monthly Plan Premium

$36.00

Total Premium:

$210.70

Note:

The standard Part B premium for 2024 is $174.70. Your Part B premium may differ based on factors including late enrollment, income, and disability status. Higher-income beneficiaries may pay an income-related monthly adjustment amount (IRMAA). The Part B premium is required to be paid by everyone enrolled in Medicare Part B.

Special needs plan type

Out-of-pocket maximum

$8850.00

Plan Organization:

UnitedHealthcare

Plan Type:

Local PPO

Location:

State of New Hampshire

Drugs Covered:

Yes

Drug Formulary:

Formulary Link

Pharmacies:

Pharmacies Link

Doctor Choice:

Any Doctor

Doctors Link:

Doctors Link

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Health deductible

Coming soon

Drug deductible

$545

Note:

This plan does not charge an annual deductible for all drugs. The $545.00 annual deductible only applies to drugs in certain tiers.

Sign up for UHC Medicare Advantage NH-001A (PPO)

Enroll online

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Drug Coverage

UHC Medicare Advantage NH-001A (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Benefit Type

Basic

Prescription drug deductible

$545.00

Increased initial coverage limit

Additional gap coverage

Part D Premium Reduction

This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.

Part D	LIS 25%	LIS 50%	LIS 75%	LIS Full
$36.00	$36.00	$36.00	$36.00	$36.00

Initial Coverage Phase

After you pay your $545.00 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 $4,660.00. Once you reach that amount, you will enter the next coverage phase.

30 Days

60 Days

90 Days

Tier	Preferred Pharmacy	Standard Pharmacy	Preferred Mail	Standard Mail
1. Preferred Generic	-	25%	-	25%
2. Standard Generic	-	-	-	-
3. Preferred Brand	-	-	-	-
4. Non-Preferred Drug	-	-	-	-
5. Specialty Tier	-	-	-	-

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.

Generic Drugs

$4.15 copay or 5% (whichever costs more)

Brand-name

$10.35 copay or 5% (whichever costs more)

Additional Benefits

UHC Medicare Advantage NH-001A (PPO) also provides the following benefits.

Note:

Limits, Authorizations, and Referrals may apply for the benefits below. Contact the plan for details.

Comprehensive dental

Non-routine services

In-Network: $0 copay

Out-Of-Network: $0 copay

Diagnostic services

In-Network: $0 copay

Out-Of-Network: $0 copay

Restorative services

In-Network: $0 copay

Out-Of-Network: $0 copay

Endodontics

In-Network: $0 copay

Out-Of-Network: $0 copay

Periodontics

In-Network: $0 copay

Out-Of-Network: $0 copay

Extractions

In-Network: $0 copay

Out-Of-Network: $0 copay

Prosthodontics, other oral/maxillofacial surgery, other services

In-Network: $0 copay

Out-Of-Network: $0 copay

Preventive dental

Oral exam

In-Network: $0 copay

Out-Of-Network: $0 copay

Cleaning

In-Network: $0 copay

Out-Of-Network: $0 copay

Fluoride treatment

In-Network: $0 copay

Out-Of-Network: $0 copay

Dental x-ray(s)

In-Network: $0 copay

Out-Of-Network: $0 copay

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures

In-Network: 20% coinsurance

Out-Of-Network: 30% coinsurance

Lab services

In-Network: $0 copay

Out-Of-Network: $0 copay

Diagnostic radiology services (eg, MRI)

In-Network: 0-20% coinsurance

Out-Of-Network: 30% coinsurance

Outpatient x-rays

In-Network: 20% coinsurance

Out-Of-Network: 30% coinsurance

Doctor visits

Primary

In-Network: 0-20% coinsurance per visit

Out-Of-Network: 30% coinsurance per visit

Specialist

In-Network: 0-20% coinsurance per visit

Out-Of-Network: 30% coinsurance per visit

Emergency care/Urgent care

Emergency

$100 copay per visit (always covered)

Urgent care

$0-40 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment

In-Network: $0 copay

Out-Of-Network: 30% coinsurance

Routine foot care

In-Network: $0 copay

Ground ambulance

Service

In-Network: 20% coinsurance

Out-Of-Network: 20% coinsurance

Hearing

Hearing exam

In-Network: 20% coinsurance

Out-Of-Network: 30% coinsurance

Fitting/evaluation

Not covered

Hearing aids

In-Network: $0 copay

Out-Of-Network: $0 copay

Inpatient hospital coverage

Service

In-Network: $1,975 per stay $0 per day for days 91 and beyond

Out-Of-Network: 30% per stay

Outpatient hospital coverage

Service

In-Network: 0-20% coinsurance per visit

Out-Of-Network: 30% coinsurance per visit

Optional benefits

Service

Medical equipment/supplies

Durable medical equipment (eg, wheelchairs, oxygen)

In-Network: 20% coinsurance per item

Out-Of-Network: 30% coinsurance per item

Prosthetics (eg, braces, artificial limbs)

In-Network: 20% coinsurance per item

Out-Of-Network: 30% coinsurance per item

Diabetes supplies

In-Network: $0 copay per item

Out-Of-Network: 30% coinsurance per item

Medicare Part B drugs

Chemotherapy

In-Network: 0-20% coinsurance

Out-Of-Network: 0-40% coinsurance

Other Part B drugs

In-Network: 0-20% coinsurance

Out-Of-Network: 0-40% coinsurance

Part B Insulin drugs

In-Network: 0-20% coinsurance (up to $35)

Out-Of-Network: 0-40% coinsurance

Mental health services

Inpatient hospital - psychiatric

In-Network: $1,935 per stay

Out-Of-Network: 30% per stay

Outpatient group therapy visit with a psychiatrist

In-Network: 20% coinsurance

Out-Of-Network: 30% coinsurance

Outpatient individual therapy visit with a psychiatrist

In-Network: 0-20% coinsurance

Out-Of-Network: 30% coinsurance

Outpatient group therapy visit

In-Network: 20% coinsurance

Out-Of-Network: 30% coinsurance

Outpatient individual therapy visit

In-Network: 0-20% coinsurance

Out-Of-Network: 30% coinsurance

Preventive care

Service

In-Network: $0 copay

Out-Of-Network: 0-30% coinsurance

Rehabilitation services

Occupational therapy visit

In-Network: 0-20% coinsurance

Out-Of-Network: 30% coinsurance

Physical therapy and speech and language therapy visit

In-Network: 0-20% coinsurance

Out-Of-Network: 30% coinsurance

Skilled Nursing Facility

Service

In-Network: Coming soon

Out-Of-Network: 30% per stay

Transportation

Service

In-Network: $0 copay

Vision

Routine eye exam

In-Network: $0 copay

Out-Of-Network: 30% coinsurance

Other

Not covered

Contact lenses

In-Network: $0 copay

Out-Of-Network: $0 copay

Eyeglasses (frames and lenses)

In-Network: $0 copay

Out-Of-Network: $0 copay

Eyeglass frames

Not covered

Eyeglass lenses

Not covered

Upgrades

Not covered

Wellness programs (eg, fitness, nursing hotline)

Service

Covered

Plan Providers

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.

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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.

* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.

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