Enrollment Guide 2021 Take advantage of all your Medicare Advantage plan has to offer. UnitedHealthcare Dual Complete® ONE (HMO D-SNP) H3113-005-000 Service area: New Jersey - Atlantic, Bergen, Burlington, Camden, Cumberland, Essex, Gloucester, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Ocean, Passaic, Salem, Somerset, Sussex, Union, Warren counties Plan Year: January 1, 2021 through December 31, 2021 Get more for your Medicare dollar. More choice and more guidance. Renew, our When it comes to Medicare, one size does not fit all. That’s why UnitedHealthcare® offers a broad range health and of Medicare products, so you have options to fit your wellness program. health care needs. UnitedHealthcare’s experienced advisors and licensed sales agents will guide you Renew can help by through choosing the plan that’s right for you. inspiring you to take charge of your health and wellness every day. Get the care you need when — It provides a wide variety and where — you need it. of useful resources and activities — including Whether it’s an appointment with your doctor brain games, healthy online, a call with a nurse at 3 a.m. or taking care recipes, learning of a wellness visit from the comfort of your home, courses, fitness activities, UnitedHealthcare makes it easier to connect you and more. All at no cost.1 with care so you can stay on top of your health — when, where, and how you need it. One-on-one help using your Medicare plan. At UnitedHealthcare®, it’s not just customer service. It’s 1-on-1 support to help answer your questions and take the extra steps to understand your needs. It’s helping navigate your care during a health event. And it’s helping you get the most out of your plan, so you can be at your best health. 1Renew by UnitedHealthcare is not available in all plans. Resources may vary. Y0066_INTRO_2021_C CSEX21DU4776506_000 Table of Contents Start with Medicare Basics......................................................................................... 4 Eligibility and Helpful Resources Plan Information Benefit Highlights................................................................................................ 8 Explore Your Additional Services.....................................................................11 My Additional Benefits...................................................................................... 12 Over-the-Counter (OTC) Benefit Renew Active™ Summary of Benefits.........................................................................................17 Plan Ratings.......................................................................................................44 Drug List Drug List.............................................................................................................48 Alternative Covered Drugs..............................................................................117 Ready to Enroll Plan Recap.......................................................................................................120 How to Enroll....................................................................................................122 Scope of Appointment Confirmation Form...................................................123 Enrollment Request Form...............................................................................125 Enrollment Receipt..........................................................................................143 Take Advantage of What’s Next.....................................................................144 Vendor Information..........................................................................................147 Questions? We're here to help. Call toll-free 1-844-560-4944, TTY 711 www.UHCCommunityPlan.com 8 a.m. - 8 p.m. local time, 7 days a week Y0066_EGTOC_2021_C UHEX21MP4713483_000 Start With Medicare Basics Review the basics to make sure this plan is a good fit Original Medicare is provided by the federal government and covers some of the costs of hospital stays (Part A) and doctor visits (Part B), but doesn’t cover everything. It does not include prescription drug coverage (Part D). Depending on your needs, you may want to add on more coverage. Original Medicare – Provided by the federal government Part A Part B Helps pay for hospital stays Helps pay for doctor visits and inpatient care and outpatient care Your options for more coverage: Option 1 OR Option 2 Add one or both of the following Choose a Medicare Advantage plan: to Original Medicare: Medicare Supplement Insurance Plan Medicare Advantage Plan Offered by private companies Offered by private companies Medicare Supplement Helps pay some of the out- Part C of-pocket costs that come Combines Part A (hospital with Original Medicare insurance) and Part B (medical insurance) in one plan Part D Medicare Part D Plan Usually includes prescription Offered by private companies drug coverage Part D May offer additional Helps pay for prescription benefits not provided by drugs Original Medicare Medicare Made ClearTM brought to you by UnitedHealthcare® 4 This is a Medicare Advantage Part C Health Maintenance Organization (HMO) plan Your plan is a Health Maintenance Organization (HMO) plan. That means you need to get healthcare services through a network of local doctors and hospitals. Here’s how your HMO plan works You will need to select a primary care provider (PCP). This health plan requires you to select a PCP from the network. Your PCP can oversee and help manage your care. You have coverage for emergency care. Emergency Services and Urgently Needed Services are covered no matter where you go. A network of providers for coordinated care The chart below shows what happens when you use network versus out-of-network resources with this plan. In-Network Out-of-Network Will the doctor or hospital Yes No accept my plan? Does this plan require a referral to see a Specialist or No No other providers? What will I pay for covered There is no copay or In most cases, you will have to services? coinsurance. pay the full cost for services. You can find a complete listing of network providers and facilities within your plan on our website. 5 Are you eligible for this plan? You are eligible for this plan if you’re enrolled in Medicare Parts A and B and receive full state Medicaid benefits (such as New Jersey Family Care A or Managed Long Term Services and Supports). Enrollment is available once per calendar quarter during the first three quarters of the year (January – September) based on your qualifying election type. What are the levels of eligibility in New Jersey? · Qualified Medicare Beneficiary Plus (QMB Plus) · Full Benefit Dual Eligible (FBDE) What are the income requirements for each eligibility level? Federal Poverty Income Social Security Income Level Level Resources not more than two QMB Plus At or lower than times Based on Medical Need status, institutionalized income levels, FBDE home/community based waivers Helpful Resources You may qualify for Extra Help Extra Help is a program for people with limited incomes who need help paying Part D premiums, deductibles and copays. To see if you qualify for Extra Help, call: · The Social Security Administration at 1-800-772-1213, TTY 1-800-325-0778 · Your state Medicaid office This information is not a complete description of benefits. Call 1-844-560-4944, TTY 711 for more information. Y0066_SWMB_2021_M H3113005000 UHNJ21HM4769854_000 6 Plan Information UHEX21MP4713485_000 7 Benefit Highlights UnitedHealthcare Dual Complete® ONE (HMO D-SNP) As a UnitedHealthcare Dual Complete® ONE (HMO D-SNP) member, you have no out-of-pocket expenses. You will not be responsible for any copayments or coinsurance for drugs or other covered services provided by plan providers. This is a short description of your 2021 plan benefits. For complete information, please refer to your Evidence of Coverage. Limitations, exclusions and restrictions may apply. Plan Costs Monthly plan premium $0 Medical Benefits Your Cost Doctor’s office visit Primary Care Provider: $0 copay Specialist: $0 copay (no referral needed) Virtual medical visits: $0 copay Preventive services $0 copay Inpatient hospital care $0 copay per stay (no limit on days) Skilled nursing facility (SNF) $0 copay per stay (no limit on days) Outpatient hospital, including surgery $0 copay Mental health (outpatient and virtual) Group therapy: $0 copay Individual therapy: $0 copay Virtual visits: $0 copay Diabetes monitoring supplies $0 copay for covered brands Diagnostic radiology services (such as $0 copay MRIs, CT scans) Diagnostic tests and procedures (non- $0 copay radiological) Lab services $0 copay Outpatient x-rays $0 copay Ambulance $0 copay for ground or air Emergency care $0 copay (worldwide) Urgently needed services $0 copay (worldwide) 8 Benefits and Services Beyond Original Medicare Your cost Acupuncture $0 copay Chiropractic Services $0 copay Plan Information Dental Services $0 copay Durable Medical Equipment (DME) $0 copay Family Planning Services and Supplies $0 copay Federally Qualified Health Centers $0 copay (FQHC) Fitness program through Renew Standard membership to participating fitness Active™ locations with access to group fitness classes – depending on availability. Programs such as, online brain exercises, activities and an in-person fitness orientation at no cost to you. For the complete details about the program, please visit www.UHCRenewActive.com, and click the link in the footer entitled Terms and Conditions. Hearing services — hearing exams and $0 copay hearing