UHC Medicare Advantage NY-0021 (PPO) Plan Details for Wyoming County, NY
CMS rated this UnitedHealthcare plan 3.5 (Above Average) out of 5 stars.
UHC Medicare Advantage NY-0021 (PPO) is a Medicare Advantage plan with Part D benefits. Enrollment for 2025 starts Oct. 15.
See more Medicare Advantage Plans in Wyoming County, New York.
2025 UHC Medicare Advantage NY-0021 Cost and Coverage Notification
The 2025 cost and coverage information for UHC Medicare Advantage NY-0021 will not be available until early October. We'll notify you as soon as it is available from CMS.
Sign-Up for 2025 Medicare Plan Notification. The 2025 Annual Enrollment Period begins October 15.
UHC Medicare Advantage NY-0021 Basic Details
| Plan Basics | |
|---|---|
| Plan ID: | R5342-005-0 |
| Plan Type: | Regional PPO |
| Plan Year: | 2024 |
| Premium: | $56.00/mo Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | $7,500/yr |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Enhanced, $195.00 deductible |
| Rx Gap Coverage: | Yes |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Wyoming County, NY |
| Insured By: | UnitedHealthcare |
| Summary of Benefits |
|---|
UnitedHealthcare Out-of-Pocket Costs
This UnitedHealthcare Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan R5342-005-0.
NOTE: Most preventive services are covered 100% by the plan as a Part B benefit.
| Healthcare Service | Member Cost |
|---|---|
| Doctor Visits (In-Network) | |
| Primary: | $0 Copay |
| Specialist: | $40 Copay Prior Authorization Required |
| Wellness programs (e.g., fitness, nursing hotline): | None |
| Preventive care: | $0 Copay |
| Foot Care (In-Network) | |
| Foot exams and treatment (Medicare-covered): | $40 Copay Prior Authorization Required |
| Routine foot care: | $40 Copay Prior Authorization Required |
| Chiropractic Care (In-Network) | |
| Medicare-covered chiropractic care: | $15 Copay Prior Authorization Required |
| Routine chiropractic care: | Not Covered |
| Emergency Care / Urgent Care | |
| Emergency room care: | $100 Copay |
| Urgent care: | $40 Copay |
| Ground ambulance: | $290 Copay |
| Inpatient hospital coverage: | $360.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
| Outpatient hospital coverage: | $310 Copay Prior Authorization Required |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $203.00 per day for days 21 and beyond |
| Optional supplemental benefits: | |
| Mental Health Services (In-Network) | |
| Outpatient individual therapy visit with a psychiatrist: | $25 Copay |
| Outpatient group therapy visit with a psychiatrist: | $15 Copay |
| Inpatient hospital - psychiatric: | $360.00 per day for days 1 through 4 $0.00 per day for days 5 and beyond |
| Outpatient group therapy visit: | $15 Copay |
| Outpatient individual therapy visit: | $0 |
| Rehabilitation Services (In-Network) | |
| Physical therapy and speech and language therapy visit: | $25 Copay Prior Authorization Required |
| Occupational therapy visit: | $25 Copay Prior Authorization Required |
| Medical Equipment / Supplies (In-Network) | |
| Diabetes supplies: | $0 Copay Prior Authorization Required |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Prior Authorization Required |
| Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
| Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
| Diagnostic radiology services (e.g., MRI): | $175 Copay Prior Authorization Required |
| Lab services: | $0 Copay Prior Authorization Required |
| Outpatient x-rays: | $25 Copay Prior Authorization Required |
| Diagnostic tests and procedures: | $45 Copay Prior Authorization Required |
| Medicare Part B Drugs (In-Network) | |
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our UHC Medicare Advantage NY-0021 Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits UnitedHealthcare includes with this plan:
| Supplemental Healthcare Service | Member Cost |
|---|---|
| Preventive Dental | |
| Oral exam (In-Network) | Not Covered |
| Fluoride treatment (In-Network) | Not Covered |
| Dental x-ray(s) (In-Network) | Not Covered |
| Cleaning (In-Network) | Not Covered |
| Comprehensive Dental | |
| Periodontics (In-Network) | Not Covered |
| Non-routine services (In-Network) | Not Covered |
| Diagnostic services (In-Network) | Not Covered |
| Extractions (In-Network) | Not Covered |
| Endodontics (In-Network) | Not Covered |
| Restorative services (In-Network) | Not Covered |
| Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
| Hearing Aids | |
| Fitting/evaluation (In-Network) | Covered Limits may apply |
| Hearing aids (In-Network) | Covered Limits may apply |
| Hearing exam (In-Network) | Not Covered |
| Vision | Maximum vision benefit: | $250.00 Every year |
| Eyeglasses (frames and lenses) (In-Network) | $0 Copay |
| Routine eye exam (In-Network) | $0 Copay Prior Authorization Required |
| Contact lenses (In-Network) | $0 Copay |
Additional Benefits
None specified.
Prescription Drug Plan Costs & Benefits
UHC Medicare Advantage NY-0021 includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans have a higher actuarial value than basic plans. Actuarial value simply refers to the percentage of cost that's covered by the plan.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. LIS, also known as Extra Help, is a Social Security program that helps people with limited income and resources lower or cut Part D costs.
The following table outlines the premium details of this prescription drug plan.
| Basic Part D Premium: | $55.50 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $55.50 |
| Part D Premium with Full LIS Assistance: | $6.80 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $195.00. You must pay this amount at the pharmacy before UnitedHealthcare begins paying its share.
NOTE: The deductible does not apply to one or more drug tiers in this plan (see "Prescription Drug Plan Out-of-Pocket Costs" below).
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, UHC Medicare Advantage NY-0021 has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Preferred | Standard |
|---|---|---|
| 1 (Preferred Generic) | N/A | $0.00 copay (deductible does not apply) |
| 2 (Generic) | N/A | $14.00 copay |
| 3 (Preferred Brand) | N/A | $47.00 copay |
| 4 (Non-Preferred Drug) | N/A | $100.00 copay |
| 5 (Specialty Tier) | N/A | 30% |
CMS 5-Star Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories using a 5-star rating system. Here are the most recent CMS ratings for UHC Medicare Advantage NY-0021.
| CMS Measure | Star Rating |
|---|---|
| 2024 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
- UHC Medicare Advantage NY-0020
- UHC Medicare Advantage NY-0021
- UHC Medicare Advantage NY-0022
- UHC Medicare Advantage Patriot No Rx NY-MA02
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact UnitedHealthcare
| Plan Website: | http://UHC.com/Medicare |
|---|---|
| Formulary Information: | http://UHC.com/Medicare |
| Pharmacy Information: | UnitedHealthcare Pharmacy Page |
| Prospective Members: | (800)555-5757 |
| TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Citations & References
- UnitedHealthcare, http://UHC.com/Medicare, Last Accessed February 20, 2024
- Medicare.gov, "Your health plan options", Last Accessed February 20, 2024
- Medicare.gov, "How Original Medicare Works", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You", Last Accessed February 19, 2024
- Medicare.gov, "What Medicare Covers", Last Accessed February 7, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.