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UHC Medicare Advantage Patriot No Rx GS-MA01 (Regional PPO) - R2604-005-000
$0.00
Monthly Premium
UHC Medicare Advantage Patriot No Rx GS-MA01 (Regional PPO) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare
Plan ID: R2604-005-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
South Carolina and Georgia 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 South Carolina and Georgia 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 | -$1.00 |
| Out-of-pocket maximum | $9,350.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | In Network In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0 to $55 Prior Authorization Required for Doctor Specialty Visit Note: $0 copayment applies to Medicare covered telehealth and Medicare covered remote monitoring. The higher cost share applies to all other Medicare covered services. Out of Network Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $55 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 | In Network In-Network: Acute Hospital Services: $475 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services 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. Out of Network Out-of-Network: Acute Hospital Services: $475 per day for days 1 to 5 $0 per day for days 6 to 999 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 In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $290 Air Ambulance: Copayment for Air Ambulance Services $290 Prior Authorization Required for Air Ambulance Out of Network Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $290 Copayment for Medicare Covered Ambulance Services - Air $290 |
Health Care Services and Medical Supplies
UHC Medicare Advantage Patriot No Rx GS-MA01 (Regional PPO) covers a range of additional benefits. Learn more about UHC Medicare Advantage Patriot No Rx GS-MA01 (Regional PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In Network In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services Out of Network Out-of-Network: Medicare Covered Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $15 |
| Diabetes supplies, training, nutrition therapy and monitoring | In Network In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 Out of Network 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) | In Network In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Out of Network 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 Tests and Procedures: $50 copay Lab Services: $0 copay Diagnostic Radiology Services: $225 copay X-rays: $40 copay |
| Home health care | In Network In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Out of Network Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 50% |
| Mental health inpatient care | In Network In-Network: Psychiatric Hospital Services: $475 per day for days 1 to 4 $0 per day for days 5 to 90 Prior Authorization Required for Psychiatric Hospital Services 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. Out of Network Out-of-Network: Psychiatric Hospital Services: $475 per day for days 1 to 4 $0 per day for days 5 to 90 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 | In Network In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $0 to $25 Copayment for Medicare-covered Group Sessions $15 Out of Network Out-of-Network: Medicare Covered Mental Health Services: Copayment for Medicare Covered Individual Sessions $25 Copayment for Medicare Covered Group Sessions $15 |
| Outpatient services/surgery | In Network In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $475 Prior Authorization Required for Outpatient Hospital Services 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 Observation Services: Copayment for Medicare Covered Observation Services - Per day $475 Prior Authorization Required for Outpatient Observation Services Benefit Details - General 9a2 Note - NOTE ON OBSERVATION SERVICES: Benefit category includes both the facility and professional component. Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $475 Prior Authorization Required for Ambulatory Surgical Center Services Benefit Details - General 9b Note - NOTE ON ASC SERVICES: Benefit category 9b includes both the facility and professional component.Benefit Details - General 9b Note - NOTE ON COST SHARING RANGE FOR ASC Services: $0 copayment for outpatient diagnostic colonoscopies. The higher cost share applies to all other outpatient procedures. Out of Network Out-of-Network: Medicare Covered Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $475 Copayment for Medicare Covered Ambulatory Surgical Center Services $0 to $475 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 | In Network In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $0 to $25 Copayment for Medicare-covered Group Sessions $15 Prior Authorization Required for Outpatient Substance Abuse Services Note: $0 copayment applies to Medicare covered telehealth for individual sessions. The higher cost share applies to all other Medicare covered services. Out of Network Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $25 Copayment for Medicare Covered Group Sessions $15 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 In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $45 Copayment for Routine Foot Care $45
Out of Network Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $45 Non-Medicare Covered Podiatry Services: Copayment for Non-Medicare Covered Podiatry Services $45 |
| Skilled Nursing Facility (SNF) care | In Network 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 Out of Network Out-of-Network: Skilled Nursing Facility Services: $225 per day for days 1 to 100 |
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 | Routine Eye Exam: $0 copay, 1 per year Routine Eyewear: Plan pays up to $200 every two years for 1 pair of frames or contact lenses. Standard single, bifocal, trifocal, or progressive lenses are covered in full. Home-delivered eyewear available nationwide only through UnitedHealthcare Vision (select products only). |
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 | In Network In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $99 to $1249
Out of Network Out-of-Network: Medicare Covered Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $55 |
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 | In Network In-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 & vaginal 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:
Yearly "Wellness" visit Out of Network Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
When reviewing South Carolina and Georgia 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 South Carolina and Georgia 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 |
South Carolina Counties Served
- Abbeville
- Aiken
- Allendale
- Anderson
- Bamberg
- Barnwell
- Beaufort
- Berkeley
- Calhoun
- Charleston
- Cherokee
- Chester
- Chesterfield
- Clarendon
- Colleton
- Darlington
- Dillon
- Dorchester
- Edgefield
- Fairfield
- Florence
- Georgetown
- Greenville
- Greenwood
- Hampton
- Horry
- Jasper
- Kershaw
- Lancaster
- Laurens
- Lee
- Lexington
- Marion
- Marlboro
- Mccormick
- Newberry
- Oconee
- Orangeburg
- Pickens
- Richland
- Saluda
- Spartanburg
- Sumter
- Union
- Williamsburg
- York
Georgia Counties Served
- Appling
- Atkinson
- Bacon
- Baker
- Baldwin
- Banks
- Barrow
- Bartow
- Ben Hill
- Berrien
- Bibb
- Bleckley
- Brantley
- Brooks
- Bryan
- Bulloch
- Burke
- Butts
- Calhoun
- Camden
- Candler
- Carroll
- Catoosa
- Charlton
- Chatham
- Chattahoochee
- Chattooga
- Cherokee
- Clarke
- Clay
- Clayton
- Clinch
- Cobb
- Coffee
- Colquitt
- Columbia
- Cook
- Coweta
- Crawford
- Crisp
- Dade
- Dawson
- Decatur
- Dekalb
- Dodge
- Dooly
- Dougherty
- Douglas
- Early
- Echols
- Effingham
- Elbert
- Emanuel
- Evans
- Fannin
- Fayette
- Floyd
- Forsyth
- Franklin
- Fulton
- Gadsden
- Gilmer
- Glascock
- Glynn
- Gordon
- Grady
- Greene
- Gwinnett
- Habersham
- Hall
- Hancock
- Haralson
- Harris
- Hart
- Heard
- Henry
- Houston
- Irwin
- Jackson
- Jasper
- Jeff Davis
- Jefferson
- Jenkins
- Johnson
- Jones
- Lamar
- Lanier
- Laurens
- Lee
- Liberty
- Lincoln
- Long
- Lowndes
- Lumpkin
- Macon
- Madison
- Marion
- Mcduffie
- Mcintosh
- Meriwether
- Miller
- Mitchell
- Monroe
- Montgomery
- Morgan
- Murray
- Muscogee
- Newton
- Oconee
- Oglethorpe
- Paulding
- Peach
- Pickens
- Pierce
- Pike
- Polk
- Pulaski
- Putnam
- Quitman
- Rabun
- Randolph
- Richmond
- Rockdale
- Russell
- Schley
- Screven
- Seminole
- Spalding
- Stephens
- Stewart
- Sumter
- Talbot
- Taliaferro
- Tattnall
- Taylor
- Telfair
- Terrell
- Thomas
- Tift
- Toombs
- Towns
- Treutlen
- Troup
- Turner
- Twiggs
- Union
- Upson
- Walker
- Walton
- Ware
- Warren
- Washington
- Wayne
- Webster
- Wheeler
- White
- Whitfield
- Wilcox
- Wilkes
- Wilkinson
- Worth
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