United Airlines - Medicare Post 65 Current Page 2
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1
2Colorado
Post 65 Retirees
United Airlines – Medicare Post 65 Current
Group Number(s): 747
Effective Dates: January 1, 2018 – December 31, 2018
Mental Health and Chemical Dependency
Mental Health Outpatient (Individual)
$20 copay
Mental Health Outpatient (Group)
$10 copay
Mental Health Inpatient
$250 copay
Chemical Dependency Outpatient (Individual)
$20 copay
Chemical Dependency Outpatient (Group)
$10 copay
Chemical Dependency Inpatient
$250 copay
Prescription Drugs
Pharmacy/Retail: Generic
$10 copay
Pharmacy/Retail: Brand
$25 copay
Pharmacy/Retail: Day Supply
30 days
Mail Order - Generic
$20 copay
Mail Order - Brand
$50 copay
Mail Order - Day Supply
90 days
Other
Skilled Nursing Facility (SNF)
100% covered; limited to 100 days per calendar year
Infertility Services
$20 copay; drugs not covered
Hospice Care
100% covered
Home Health Care
100% covered
Durable Medical Equipment (DME)
80% covered
Chiropractic Care
$20 copay for manual manipulation of the spine to correct subluxation
Notes
This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, cost sharing, out-of-pocket maximums, exclusions, or
limitations, nor does it list all benefits and cost sharing. For a complete explanation, please refer to the applicable EOC, or to the Disclosure Form for
California, or to the Member Handbook for Hawaii.
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