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BenefitCopay and coinsurance guidelinesCOVID-19Vaccinations andMonoclonalAntibodyTherapyCovered services include the following, administered in accordance with currentMedicare coverage guidelines published by CMS: COVID-19 vaccines, including boosters Monoclonal antibody COVID-19 infusionThere is no copay, coinsurance or deductible.There’s no office visit cost share if the immunization or vaccination was the onlyreason for the visit.The office visit cost share may apply if services that would incur a cost share wereprovided during the same visit as the immunization or vaccination.Drugs for treatment of COVID symptoms are not covered by Medicare but may becovered under Medicare Part D.DepressionScreeningFor more information: onavirus-COVID19/covid19-vaccines.html cms.gov/covidvax-providerWe cover 1 screening for depression per year in a primary care setting that canprovide follow-up treatment and referrals. Annual depression screenings maybe performed separately by a primary care provider and can take place duringa scheduled office visit.All Medicare-covered preventive services can be provided any time during thecalendar year in which the member is eligible to receive the service. There isno copay, coinsurance or deductible.The “Welcome to Medicare” visit and first annual wellness visit include anannual depression screening. If a member needs further evaluation todiagnose their condition, or if they need mental health treatment, refer them toa mental health professional.DiabetesSelf-ManagementTrainingFor more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Preventive Health Services and Procedures – Medicare AdvantageCoverage Summary Up to 10 hours of training per year in 30-minute group sessions. This includeseducation about how to monitor blood sugar, diet, exercise, medication andreducing risks. We cover individual sessions if no group sessions are availableor if you believe special needs prevent the member from participating in agroup setting. May also qualify for up to 2 hours of follow-up training each year when orderedby you or another provider as part of the patient’s care plan. The follow-uptraining must take place in a calendar year after the date the initial trainingwas received.All Medicare-covered preventive services can be provided any time during thecalendar year in which the member is eligible to receive the service. There isno copay, coinsurance or deductible.For more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Diabetes Management, Equipment and Supplies – Medicare AdvantageCoverage SummaryPCA-1-21-04614-M&R-FAQ 122020216

BenefitCopay and coinsurance guidelinesDiabetesScreening(Fasting PlasmaGlucose)Diabetes screening is covered when provided, according to Medicarecoverage guidelines: The member has any of the following risk factors: High blood pressure (hypertension) History of abnormal cholesterol and triglyceride levels (dyslipidemia) Obesity History of high blood sugar (glucose) Overweight with a family history of diabetes The member may be eligible for up to 2 diabetes screenings a yearbased on test resultsAll Medicare-covered preventive services can be provided any time during thecalendar year in which the member is eligible to receive the service. There isno copay, coinsurance or deductible.Diabetes SelfManagementTraining, DiabeticServicesand SuppliesFor more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Preventive Health Services and Procedures – Medicare AdvantageCoverage SummaryCovered services are subject to the diabetic supplies cost share and includesupplies to monitor blood glucose: Blood glucose monitor Blood glucose test strips Lancet devices and lancets Glucose-control solutions for checkingthe accuracy of test strips and monitorsTherapeutic continuous glucose monitors (CGMs) are subject to the same costshare as the diabetic-monitoring supplies, not the DME cost share. Coverage isin accordance with Medicare guidelines; CGMs not covered by Medicare willbe denied.For more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Diabetes Management, Equipment and Supplies – Medicare AdvantageCoverage SummaryInsulin and insulin syringesInsulin and insulin syringes are covered under the Medicare Part D prescriptiondrug benefit.Insulin pumps worn outside the body are subject to the durable medical equipmentcost share.PCA-1-21-04614-M&R-FAQ 122020217

BenefitCopay and coinsurance guidelinesDialysisThe outpatient dialysis treatment cost share applies for dialysis and all relatedservices performed in a dialysis facility, whether in or out of the service area. A separate Medicare Part B drug cost share is assessed for medicationsadministered in the dialysis facility and billed separately from thedialysis service For dialysis performed in an inpatient hospital, the inpatient hospital costshare applies For dialysis (peritoneal or hemodialysis) in a member’s home and for homesupport services such as visits by trained dialysis workers, the home healthagency cost share applies For home dialysis equipment and supplies and for certain drugs for homedialysis, the durable medical equipment (DME) and related supplies costshare appliesDME andRelated SuppliesEmergency andUrgent ServicesFor more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Dialysis Services – Medicare Advantage Coverage SummaryThe DME cost share applies to all medically necessary, Medicare-coveredDME and related supplies including, but not limited to: Wheelchairs, crutches, powered mattress systems, hospital beds ordered by aprovider for use in the home, IV infusion pumps, speech-generating devices,oxygen equipment, nebulizers and walkersFor more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Durable Medical Equipment, Prosthetics, Corrective Appliances/Orthotics andMedical Supplies – Medicare Advantage Coverage Summary Durable Medical Equipment (DME), Prosthetics, CorrectiveAppliances/Orthotics (Non-Foot Orthotics) and Medical Supplies – Grid –Medicare Advantage Coverage SummaryThe applicable cost share for emergency and urgently needed services, includingworldwide emergency coverage, varies by benefit plan. An emergency department copay applies but may be waived if the emergencydepartment visit results in admission. Please refer to the member’s evidence ofcoverage for details. An urgent care cost share applies. Additional cost shares may apply dependingon services received.For more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Emergent/Urgent Services, Post-Stabilization Care and Out-of-Area Services –Medicare Advantage Coverage SummaryPCA-1-21-04614-M&R-FAQ 122020218

BenefitCopay and coinsurance guidelinesImmunizationsand VaccinationsCovered services include: Pneumonia vaccine Flu shots, each flu season in the fall and winter, with additional flu shotsif medically necessary (flu shots are covered for a 0 copay with bothin-network and out-of-network providers) Hepatitis B vaccine for members at high or intermediate risk Other vaccines if members are at risk and they meet Medicare Part Bcoverage rulesAll Medicare-covered preventive services can be provided any time during thecalendar year in which the member is eligible to receive the service. There is nocopay, coinsurance or deductible.There’s no office visit cost share if the immunization or vaccination was the onlyreason for the visit.The office visit cost share may apply if services that would incur a cost share wereprovided during the same visit as the immunization or vaccination.Other vaccinations and immunizations not covered by Medicare may be coveredunder Medicare Part D.Inpatient HospitalAdmissions andCareFor more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Preventive Health Services and Procedures – Medicare AdvantageCoverage SummaryDepending on the member’s benefit plan, an all-inclusive inpatient hospital costshare may apply: If the member’s plan requires a per-day copay, the member will have a copayfor each day and/or hospital for the same admission. Once the memberreaches the copay maximum, or their out-of-pocket maximum, there’s noadditional copay. If the member’s plan requires a per-admission copay, the member isresponsible for 1 copay for the admission, even if they’re transferred to anotherhospital during the same stay If the member’s plan requires coinsurance, the coinsurance amountapplies per admit for each hospital stay and also applies to professionalservices in addition to the hospital charges. These amounts are capped at acertain amount depending on the plan, or until the member reaches theout-of-pocket maximum. Some plans cover unlimited days for each hospital stay while other plans followOriginal Medicare coverage and limit inpatient hospital stays to 90 days perbenefit period Transfer to a separate facility type, such as an inpatient rehabilitation hospital,is considered a new admission For mental health admissions, some benefit plans may have a differentinpatient acute hospital cost share: either a different per-day copay or differentmaximum number of daysFor more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Hospital Services (Inpatient and Outpatient) – Medicare AdvantageCoverage SummaryPCA-1-21-04614-M&R-FAQ 122020219

BenefitCopay and coinsurance guidelinesLaboratoryServicesThe laboratory cost share applies per day per provider, not per laboratory test. Toprevent multiple lab cost shares for a single visit, all lab services must be billed bythe same provider on the same date of service on a single claim.If a member has blood drawn or a specimen collected at the physician’s office,cost sharing is not assessed for venipuncture or labs billed with an office placeof service: An additional cost share for the physician office visit isn’t assessed if the blooddraw or specimen collection was the primary reason for the member’s visit An additional cost share for the physician office visit may apply if otherphysician services are renderedIf a member goes to an outpatient hospital or freestanding lab for lab servicesonly, the lab cost share applies.If a re-draw is required, members will not be assessed an additional labcost share.Additional lab cost shares may apply for labs performed on later dates.The lab cost share assessed cannot exceed the total contracted or payableamount of the lab charges per visit. The member’s cost share should not exceedthe provider’s reimbursement rate.Lab tests associated with the following Medicare-covered preventive services willnot be assessed a cost share, including but not limited to: Pap smear Colorectal, prostate and cardiovascular screeningsMedicalNutritionalTherapyFor more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Laboratory Tests and Services – Medicare Advantage Coverage SummaryMedical nutritional therapy is covered for members with diabetes or renal disease,or after a kidney transplant when referred by their doctor, including: Three hours of individual counseling during their first year and 2 hours eachyear after that If the member’s condition, treatment or diagnosis changes, the member mayreceive additional hours of treatmentAll Medicare-covered preventive services can be provided any time during thecalendar year in which the member is eligible to receive the service. There isno copay, coinsurance or deductible.For more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Diabetes Management, Equipment and Supplies – Medicare AdvantageCoverage SummaryPCA-1-21-04614-M&R-FAQ 1220202110

BenefitCopay and coinsurance guidelinesMedicare Part B:OutpatientInjectable andInfusionMedicationsPhysician-administered outpatient injectable and infusionmedication policies: The Medicare Part B drug cost share applies, per drug per day, for coveredoutpatient injectable drugs when administered at the physician’s office If the injectable medication is given in the physician’s office and an office visit isbilled, cost sharing for both the physician office visit and the injectable drugmay apply There is no separate cost share, other than the office visit cost share, foradministering the injection Refer to “Immunizations and Vaccinations” on page 9 for more information oncost sharing When an injectable medication is administered in an outpatient hospital setting,cost sharing for both the outpatient hospital services and the injectable drugmay applyHome health injectable and infusion drug policies: Medically necessary medications dispensed for home infusion therapy that areadministered through an infusion pump are covered under either Medicare PartB or the Part D prescription drug benefit, depending on the medication Medically necessary medications dispensed for home infusion therapy that areadministered as injectables are covered under Medicare Part D To authorize these services, continue using the established protocol based onyour contract with UnitedHealthcare Medicare Advantage or its affiliates. If youhave questions, call the Provider Services number on the member’s ID card. A cost share for durable medical equipment and components may apply whenthe medications are administered in a home settingSelf-administered outpatient injectable and infusion medications We cover self-administered outpatient injectable and infusion medicationsunder the Medicare Part D prescription drug benefitChemotherapy Chemotherapy drugs are Medicare Part B drugs when administered in anoutpatient or office setting, regardless of the method of administration The chemotherapy drug cost share applies to the chemotherapy drug andits administration Chemotherapy drugs administered in the home by infusion may be eitherPart B or Part DImmunosuppressive drugsThe Medicare Part B cost share applies to all members for coveredimmunosuppressive drugs provided post-transplant.For more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Medications/Drugs (Outpatient/Part B) – Medicare AdvantageCoverage Summary Chemotherapy and Associated Drugs and Treatments – Medicare AdvantageCoverage Summary Organ and Tissue Transplants – Medicare Advantage Coverage SummaryPCA-1-21-04614-M&R-FAQ 1220202111

BenefitCopay and coinsurance guidelinesMental Health –InpatientSome benefit plans have a different inpatient acute hospital cost share for mentalhealth admissions — either a different per day amount or different maximumnumber of days. Covered services include: Mental health services that require a hospital stay with a 190-day lifetime limitfor inpatient services in a psychiatric hospital. The 190-day limit doesn’t applyto mental health services provided in a psychiatric unit of a general hospital. Inpatient substance abuse servicesNon-RadiologicalDiagnostic TestsObesityScreeningand CounselingFor more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Mental Health Services and Procedures – Medicare AdvantageCoverage SummaryA non-radiological diagnostic cost share applies to the following common tests: ECG EKG Holter monitor Pulmonary function testing Sleep studies Stress tests Treadmill Stationary bicycle Continuous electrocardiographic monitoring Pharmacological stressFor more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Cardiovascular Diagnostic and Therapeutic Procedures – Medicare AdvantageCoverage Summary Sleep Apnea Diagnosis and Treatment – Medicare AdvantageCoverage Summary Respiratory Therapy, Pulmonary Rehabilitation and Pulmonary Services –Medicare Advantage Coverage SummaryMedicare covers body mass index (BMI) screenings and behavioral counseling ina primary care setting for members who meet the clinical definition of obese: BMI30 or higher. Obesity screening is covered once per year.Obesity counseling coverage includes: One in-person visit every week for the first month One in-person visit every other week during months 2–6 One in-person visit every month during months 7–12, if they lose at least6.6 pounds within the first six monthsAll Medicare-covered preventive services can be provided any time during thecalendar year in which the member is eligible to receive the service. There is nocopay, coinsurance or deductible.For more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Preventive Health Services and Procedures – Medicare Advantage CoverageSummaryPCA-1-21-04614-M&R-FAQ 1220202112

BenefitCopay and coinsurance guidelinesObservation CareHospital observation billed with an emergency room place of service is subject tothe emergency services cost share. Observation billed with an outpatient hospitalplace of service is subject to the outpatient hospital cost share.If emergency room and observation are billed together, only the emergency roomcost share applies.Observation services shouldn’t be billed concurrent with diagnostic or therapeuticservices that include active monitoring. A separate cost share applies to diagnosticor therapeutic services billed with observation, when appropriate.Opioid TreatmentProgramServicesOutpatientHospital ServicesFor more information: UHCProvider.com Policies and Protocols For Medicare Advantage Plans Coverage Summaries for MedicareAdvantage Plans Observation Care (Outpatient Hospital) – Medicare AdvantageCoverage SummaryOpioid use disorder treatment services are covered under Medicare Part B.Members receive coverage for these services through the plan. Covered servicesare subject to an outpatient Opioid Treatment Services cost share and include: FDA-approved opioid agonist and antagonist treatment medications and thedispensing and administration of such medications, if applicable Substance use counseling Individual and group therapy Toxicology testingMedically necessary services provided in an outpatient facility or outpatientdepartment of a hospital for diagnosis or treatment are covered and may besubject to applicable cost sharing depending on the member’s filed benefit.When members receive services for multiple benefit categories during the samevisit, a separate cost share may apply for each service received. The followingbenefit categories may incur a separate cost share: Medicare Part B drugs, including chemotherapy andchemotherapy administration Blood Physical, occupational, speech and pu

medical condition that’s treated or monitored during a preventive visit. All UnitedHealthcare Medicare Advantage plans cover Medicare-covered preventive services for a 0 copay with a network provider. We follow the Centers for Medicare & Medicaid Services (CMS) Medicare