AARP Medicare Advantage Giveback from UHC PA-12 (PPO) - H2406-101-000

4 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

AARP Medicare Advantage Giveback from UHC PA-12 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare

Plan ID: H2406-101-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

Pennsylvania 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 Pennsylvania 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	$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$495.00
Out-of-pocket maximum	$8,900.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$2,000.00
Primary care doctor visit	Annual Physical Exam - Routine$0 copay, 1 per year Additional Telehealth Services$0 copay to talk with a telehealth provider online through live audio and video.
Specialty doctor visit	Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $80 Note: $0 copayment applies to Medicare covered telehealth and Medicare covered remote monitoring. The higher cost share applies to all other Medicare covered services.
Inpatient hospital care	Out-of-Network: Acute Hospital Services: Coinsurance for Acute Hospital Services per Stay 40% Note: All inpatient substance abuse and mental health care (including both care received in an acute care facility and a Medicare-certified psychiatric facility) are included in category 1b.
Urgent care	Urgent Care: Copayment for Urgent Care $0 to $45 Note: $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
Emergency room visit	Emergency Care: Copayment for Emergency Care $110 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0 Copayment for Worldwide Emergency Transportation $0
Ambulance transportation	In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $275 Air Ambulance: Copayment for Air Ambulance Services $275 Prior Authorization Required for Air Ambulance

Health Care Services and Medical Supplies

AARP Medicare Advantage Giveback from UHC PA-12 (PPO) covers a range of additional benefits. Learn more about AARP Medicare Advantage Giveback from UHC PA-12 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage	Details
Chiropractic services	Out-of-Network: Medicare Covered Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $80
Diabetes supplies, training, nutrition therapy and monitoring	Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 50% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 50%
Durable medical equipment (DME)	Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 50%
Diagnostic tests, lab and radiology services, and X-rays	Diagnostic Procedure/Test$45 copay Lab Services$0 copay Diagnostic Radiology Services$200 copay X-rays$25 copay
Home health care	Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 50%
Mental health inpatient care	Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 40% Benefit Details - General Note - NOTE ON INPATIENT SUBSTANCE ABUSE: All inpatient substance abuse and mental health care (including both care received in an acute care facility and a Medicare-certified psychiatric facility) are included in category 1b.
Mental health outpatient care	Out-of-Network: Medicare Covered Mental Health Services: Copayment for Medicare Covered Individual Sessions $40 Copayment for Medicare Covered Group Sessions $30
Outpatient services/surgery	Out-of-Network: Medicare Covered Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% Note: $0 copayment for outpatient diagnostic colonoscopies. The higher cost share applies to all other outpatient procedures.Note: Benefit category includes both the facility and professional component.
Outpatient substance abuse care	Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $40 Copayment for Medicare Covered Group Sessions $30 Note: $0 copayment applies to Medicare covered telehealth for individual sessions. The higher cost share applies to all other Medicare covered services.
Podiatry services	In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $40 Copayment for Routine Foot Care $40 Maximum 6 visits every year Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) care	In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $203 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services

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	$0 copay for covered network preventive services such as oral exams, routine cleanings, X-rays, and fluoride You will have access to Medicare Advantage's largest dental network, or you can choose any dentist. Seeing a network dentist may save you money.

Vision Benefits

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

Coverage	Details
Vision care	Vision - Routine - Eye Exam $0 copay, 1 per year

Hearing Benefits

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

Coverage	Details
Hearing care	Out-of-Network: Medicare Covered Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $80

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 Medicare-covered Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 40%

Prescription Drug Costs and Coverage

The AARP Medicare Advantage Giveback from UHC PA-12 (PPO) offers prescription drug coverage, with an annual drug deductible of $495.00 (excludes Tiers 1 and 2)

Coverage & Cost 30 day supply 60 day supply 90 day supply
Coverage	Cost 30 day supply 60 day supply 90 day supply
Annual drug deductible	$495.00 (excludes Tiers 1 and 2)
Tier 1	Standard retail $0.00 Standard retail $0.00 Standard retail $0.00 Preferred mail order N/A Preferred mail order N/A Preferred mail order N/A Standard mail order N/A Standard mail order N/A Standard mail order N/A
Tier 2	Standard retail $14.00 Standard retail $14.00 Standard retail $14.00 Preferred mail order N/A Preferred mail order N/A Preferred mail order N/A Standard mail order N/A Standard mail order N/A Standard mail order N/A
Annual drug deductible	$495.00 (excludes Tiers 1 and 2)
Tier 1	Standard retail N/A Standard retail N/A Standard retail N/A Preferred mail order N/A Preferred mail order N/A Preferred mail order N/A Standard mail order N/A Standard mail order N/A Standard mail order N/A
Tier 2	Standard retail N/A Standard retail N/A Standard retail N/A Preferred mail order N/A Preferred mail order N/A Preferred mail order N/A Standard mail order N/A Standard mail order N/A Standard mail order N/A
Annual drug deductible	$495.00 (excludes Tiers 1 and 2)
Tier 1	Standard retail $0.00 Standard retail $0.00 Standard retail $0.00 Preferred mail order $0.00 Preferred mail order $0.00 Preferred mail order $0.00 Standard mail order $0.00 Standard mail order $0.00 Standard mail order $0.00
Tier 2	Standard retail $42.00 Standard retail $42.00 Standard retail $42.00 Preferred mail order $0.00 Preferred mail order $0.00 Preferred mail order $0.00 Standard mail order $42.00 Standard mail order $42.00 Standard mail order $42.00

When reviewing Pennsylvania 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 Pennsylvania that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Pennsylvania Counties Served

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

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