UHC Dual Complete NC-V001 (HMO-POS D-SNP)
H5253 - 116 - 0
(4.5 / 5)
UHC Dual Complete NC-V001 (HMO-POS D-SNP) is a Medicare Advantage (Part C) Special Needs Plan by UnitedHealthcare.
This page features plan details for 2024 UHC Dual Complete NC-V001 (HMO-POS D-SNP) H5253 – 116 – 0 available in Select Counties in North Carolina.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
UHC Dual Complete NC-V001 (HMO-POS D-SNP) is offered in the following locations.
Plan Overview
UHC Dual Complete NC-V001 (HMO-POS D-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Dual-Eligible |
| Conditions Covered: |
| Insurer: | UnitedHealthcare |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,600 In-network |
| Drugs Covered: | Yes |
Please Note:
- This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.
- Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.
Ready to sign up for UHC Dual Complete NC-V001 (HMO-POS D-SNP) ?
Premium Breakdown
UHC Dual Complete NC-V001 (HMO-POS D-SNP) has a monthly premium of $46.90. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $174.70 | $0.00 | $46.90 | $0.00 | $221.60 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
UHC Dual Complete NC-V001 (HMO-POS D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $545.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Basic |
| Additional Gap Coverage: | No |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.
The table below shows how the LIS impacts the Part D premium of this plan.
| Part D | LIS Full |
|---|---|
| $46.90 | $0.00 |
NOTE: The Inflation Reduction Act of 2022 has expanded full subsidy eligibility under the LIS program to individuals with incomes up to 150% of the Federal Poverty Level. People who qualify for Extra Help generally will pay no more than $4.50 for each generic drug and $11.20 for each brand-name drug.
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 $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 25% | 25% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 25% | 25% |
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00, you will pay no more than the amounts below for any drug tier until you reach $8,000.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| Generic drugs | ||||
| Brand-name drugs |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| Generic drugs | ||||
| Brand-name drugs |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
UHC Dual Complete NC-V001 (HMO-POS D-SNP) also provides the following benefits.
| $0 |
| In-network | No |
| $3,600 In-network |
| No |
| In-network | Yes, contact plan for further details |
| In-network | $0 or $0-295 copay per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| In-network Specialist | $0 or $0-15 copay per visit (Authorization is required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $0 or $135 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $0 or $0-40 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0 or $20 copay (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $0 or $0-225 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $0 or $25 copay (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $0 copay (Authorization is required.) (Referral is not required.) |
| Fitting/evaluation | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Hearing aids | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Non-routine services | 0-50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic services | 0-50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Restorative services | 0-50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Endodontics | 0-50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Periodontics | 0-50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Extractions | 0-50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | 0-50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | 0-50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $0 or $0-15 copay (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $0 or $0-15 copay (Authorization is required.) (Referral is not required.) |
| In-network | $0 or $275 copay (Not applicable.) (Not applicable.) |
| In-network | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Foot exams and treatment | $0 or $15 copay (Authorization is required.) (Referral is not required.) |
| In-network Routine foot care | $15 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 0% or 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 0% or 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0% or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0% or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | 0% or 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| In-network | $0 or $295 per day for days 1 through 6 $0 per day for days 7 through 90 $0 per day for days 91 and beyond (Authorization is required.) (Referral is not required.) |
| out-of-network | Not Applicable (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $0 or $295 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | Not Applicable (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $0 or $15 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $0 or $0-25 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $0 or $15 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $0 or $0-25 copay (Authorization is required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $0 or $203 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | Not Applicable (Authorization is required.) (Referral is not required.) |
Ready to sign up for UHC Dual Complete NC-V001 (HMO-POS D-SNP) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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