UHC Medicare Advantage VT-001A (PPO) H0271-012-000 2024 Plan Details and Costs (2024)

$43.50 Monthly Premium

UHC Medicare Advantage VT-001A (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare

Plan ID: H0271-012-000

$43.50 Monthly Premium

Vermont Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Vermont Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage Details
Monthly plan premium$43.50
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$545.00
Out-of-pocket maximum$8,850.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Coinsurance for Primary Care Office Visit 0% to 20%

Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 30%

Inpatient hospital care
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 30%
Urgent care
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.

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0.00

Emergency room visit
Emergency Care:
Copayment for Emergency Care $100.00
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 transportationIn-Network:

Ground Ambulance:
Coinsurance for Ground Ambulance Services 20%

Air Ambulance:
Coinsurance for Air Ambulance Services 20%

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 Medicare Advantage VT-001A (PPO) covers a range of additional benefits. Learn more about UHC Medicare Advantage VT-001A (PPO) 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%

Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies and Services 30%

Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment

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
Out-of-Network:

Home Health Services:
Coinsurance for Medicare Covered Home Health 40%

Mental health inpatient care
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 30%
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Coinsurance for Medicare-covered Individual Sessions 0% to 20%
Coinsurance for Medicare-covered Group Sessions 20%
Prior Authorization Required for Outpatient Mental Health Services

Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 0% to 20%
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Coinsurance for Medicare Covered Observation Services 20%
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Coinsurance for Ambulatory Surgical Center Services 0% to 20%
Prior Authorization Required for Ambulatory Surgical Center Services

Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare-covered Individual Sessions 0% to 20%
Coinsurance for Medicare-covered Group Sessions 20%
Prior Authorization Required for Outpatient Substance Abuse Services

Over-the-counter items
Out-of-Network:

Over-The-Counter (OTC) Items:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $100.00

Podiatry services
Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 30%
Podiatry Services:
Coinsurance for Non-Medicare Covered Podiatry Services 30%

Skilled Nursing Facility (SNF) care
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 30%

Dental Benefits

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

Coverage Details
Dental careIn-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:
Coinsurance for Medicare-covered Benefits 20%
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 benefitsIn-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 $200.00 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
Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 30%
Non-Medicare Covered Hearing Services:
Coinsurance for Non-Medicare Covered Hearing Exams 30%
Copayment for Non-Medicare Covered Hearing Aids $0.00

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 programsIn-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vagin*l cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The UHC Medicare Advantage VT-001A (PPO) offers prescription drug coverage, with an annual drug deductible of $545.00 (excludes Tiers 1 and 2)

    Coverage

    Cost

    Coverage & Cost

    Annual drug deductible$545.00 (excludes Tiers 1 and 2)
    Tier 1
  • Standard retail 25%
  • Preferred mail order N/A
  • Standard mail order N/A
  • Tier 2
  • Standard retail 25%
  • Preferred mail order N/A
  • Standard mail order N/A
  • Annual drug deductible$545.00 (excludes Tiers 1 and 2)
    Tier 1
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
  • Tier 2
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
  • Annual drug deductible$545.00 (excludes Tiers 1 and 2)
    Tier 1
  • Standard retail 25%
  • Preferred mail order 25%
  • Standard mail order 25%
  • Tier 2
  • Standard retail 25%
  • Preferred mail order 25%
  • Standard mail order 25%
  • When reviewing Vermont 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 Vermont 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

    Vermont Counties Served

    Addison Bennington Caledonia Chittenden Essex Franklin Grand Isle Lamoille Orange Orleans Rutland Washington Windham Windsor

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

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    UHC Medicare Advantage VT-001A (PPO) H0271-012-000 2024 Plan Details and Costs (2024)
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