H5253 041
H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week www.UHCCommunityPlan.com Y0066_SB_H5253_041_000_2022_M
Y0066_EOC_H5253_041_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of Coverage
2022 UnitedHealthcare Dual Complete (HMO-POS D-SNP) - H5253-041-0 in NC Plan Benefits Details 2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H5253-041-000; 2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H5253-116-000; 2023 UnitedHealthcare Dual Complete Plan Frequently Asked Questions H1889-005-000; 2023 UnitedHealthcare Dual Complete Plan Frequently Asked Questions H5253-041-000 H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5253_041_000_2023_M Sep 26, 2022 · AARP® Medicare Advantage Plan 2 (HMO-POS) dummy spacing Benefits In-Network Inpatient Hospital Care2 $250 copay per day: days 1-5 $0 copay per day: days 6 and beyond Our plan covers an unlimited number of days for an Oct 1, 2022 · Wellcare by Health Net for California Post Office Box 10420 Van Nuys, CA 91410 From October 1 – March 31, you can call us 7 days a week from 8 a.m. to 8 p.m.
2020 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Guilford, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. 2023 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Durham, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. The UnitedHealthcare Dual Complete (HMO-POS D-SNP) (H5253 - 041) currently has 43,512 members. There are 545 members enrolled in this plan in Orange, North Carolina, and 43,321 members in North Carolina. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars. 2021 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Catawba, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. Number of Members enrolled in this plan in (H5253 - 041): 23,173 members : Plan’s Summary Star Rating: 4 out of 5 Stars. • Customer Service Rating: 5 out of 5 Stars. • Member Experience Rating: 4 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split as Follows: : Total ... Original Medicare. Oak Street Health High Point accepts Original Medicare Part A and Part B plans. Also known as traditional Medicare, Original Medicare is a fee-for-service plan, with Medicare paying a portion of the bill for Medicare covered services. Our High Point, North Carolina locations accept Part B plans, though some require both Part ... 1-800-MEDICARE (1-800-633-4227) TTY users 1-877-486-2048. or contact your local SHIP for assistance. Email a copy of the AARP Medicare Advantage Plan 1 (HMO-POS) benefit details. — Medicare Plan Features —. Monthly Premium: $27.00 (see Plan Premium Details below) Annual Deductible: $0. Sep 1, 2023 · UnitedHealthcare Dual Complete (HMO-POS D-SNP) You're viewing plan details for. 27053 Alamance County. Update your ZIP Code to view accurate plan details for your area. Monthly Premium. $ 0 - $ 38.40. Primary Care Provider. $ 0 copay - 20 % of the cost. Out-of-Pocket Maximum.
TTY users 1-877-486-2048. or contact your local SHIP for assistance. Email a copy of the AARP Medicare Advantage Plan 2 (HMO-POS) benefit details. — Medicare Plan Features —. Monthly Premium: $28.00 (see Plan Premium Details below) Annual Deductible: $0. Annual Initial Coverage Limit (ICL): Original Medicare. Dr. Miller accepts Original Medicare Part A and Part B plans. Also known as traditional Medicare, Original Medicare is a fee-for-service plan, with Medicare paying a portion of the bill for Medicare covered services. Our Durham, North Carolina locations accept Part B plans, though some require both Part A and Part B. UnitedHealthcare offers UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 plans for North Carolina and eligible counties. This plan gives you a choice of doctors and hospitals. Learn about lookup tools. The UnitedHealthcare Dual Complete (HMO-POS D-SNP) (H5253 - 041) currently has 34,004 members. There are 441 members enrolled in this plan in Stokes, North Carolina, and 33,873 members in North Carolina. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 4 stars.
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o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 - UD5 Datos del miembro (escriba a máquina o en letra de molde con tinta negra o azul) Apellidos Nombre Inicial del segundo nombre Fecha de nacimiento Sexo ¨ Masculino ¨ Femenino We would like to show you a description here but the site won’t allow us. Maximum 3 visits every year. Copayment for Fluoride Treatment $0.00. Maximum 2 visits every year. Copayment for Dental X-Rays $0.00. Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $4000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined. For Person County’s Medicare beneficiaries, Medicare Advantage plans offer an alternative to Original Medicare. Currently, 53 MA plans are available in Person County, and coverage is provided through Medicare-approved private companies, following rules set by Medicare.
Learn more about the UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 plan for North Carolina. Check eligibility, explore benefits, and enroll today. Hmm … it looks like your browser is out of date. H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week www.UHCCommunityPlan.com Y0066_SB_H5253_041_000_2022_M H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week www.UHCCommunityPlan.com Y0066_SB_H5253_041_000_2022_M. www.UHCCommunityPlan.com 2020 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Guilford, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. Y0066_ANOC_H5253_041_000_2023_M. Y0066_210610_INDOI_C Find updates to your plan for next year This notice provides information about updates to your plan, but it ... H5253-041-000 Consulte esta guía y aproveche las coberturas de medicamentos y los servicios de salud que proporciona el plan. Llame a Servicio al Cliente o visite el sitio web para obtener más información sobre el plan. Llamada gratuita 1-855-545-9340, TTY 711 8 a.m. a 8 p.m., hora local, los 7 días de la semana UHCCommunityPlan.com 2021 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Catawba, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. The UnitedHealthcare Dual Complete (HMO-POS D-SNP) (H5253 - 041) currently has 34,004 members. There are 441 members enrolled in this plan in Stokes, North Carolina, and 33,873 members in North Carolina. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 4 stars.
Jan 1, 2023 · H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5253_041_000_2023_M
For Person County’s Medicare beneficiaries, Medicare Advantage plans offer an alternative to Original Medicare. Currently, 53 MA plans are available in Person County, and coverage is provided through Medicare-approved private companies, following rules set by Medicare. o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 - UD5 Datos del miembro (escriba a máquina o en letra de molde con tinta negra o azul) Apellidos Nombre Inicial del segundo nombre Fecha de nacimiento Sexo ¨ Masculino ¨ Femenino 2020 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Guilford, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5253_041_000_2023_M Jan 1, 2023 · Enrollment Guide 2023 Take advantage of all your Medicare Advantage plan has to offer UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 Service area: North Carolina - Alamance, Alexander, Anson, Bertie, Bladen, Buncombe, Burke, 533 Medicare Advantage Plans from UnitedHealthcare. Coverage varies by plan. Select a Medicare Advantage Plan below to view details about the coverage it provides: Plan CodePlan Name. H0271:007-0 UnitedHealthcare Medicare Advantage Assure (PPO) H0271:012-0 UnitedHealthcare Medicare Advantage Assure (PPO) H0271:017-0 UnitedHealthcare Medicare ... The following UnitedHealthCare plans are accepted at Oak Street Health locations. Plan Name. Effective Year. Benefit Package. Summary. AARP Medicare Advantage. 2023. H1944-024. AARP Medicare Advantage.
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o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 - UD5 Information about you (Please type or print in black or blue ink) Last Name First Name Middle Initial Birth Date Sex ¨ Male ¨ Female Home Phone Number ( ) - Mobile Phone Number ( ) - Social Security Number Sep 26, 2022 · Summary of Benefits 2023 UnitedHealthcare Dual Complete® Select (HMO-POS D-SNP) H5253-116-000 Look inside to take advantage of the health services and drug coverages the plan provides. Sep 27, 2022 · 1 2023-H3146.006.1 H3146-006 Aetna Medicare Value Plus Plan (HMO) H3146 ‑ 006 Here’s a summary of the services we cover from January 1, 2023 through Decembe Guía de Inscripción 2023 Aproveche todo lo que su plan Medicare Advantage tiene para ofrecer UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 Área de servicio: North Carolina - condados de Alamance, Alexander, Anson, Bertie, Bladen, 2021 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Davidson, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. Feb 22, 2011 · Medicare Advantage & Other Health Plans in Iowa 2023 Iowa Insurance Division 1963 Bell Ave, Suite 100, Des Moines, IA 50315 1-800-351-4664 TTY 1-800-735-2942 Jan 1, 2023 · Enrollment Guide 2023 Take advantage of all your Medicare Advantage plan has to offer UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 Service area: North Carolina - Alamance, Alexander, Anson, Bertie, Bladen, Buncombe, Burke, Jan 1, 2023 · Summary of Benefits 2023 AARP® Medicare Advantage Plan 1 (HMO-POS) H5253-111-001 Look inside to take advantage of the health services and drug coverages the plan provides. 2022 UnitedHealthcare Dual Complete (HMO-POS D-SNP) - H5253-041-0 in NC Plan Benefits Details Copayment for Dental X-Rays $0.00. Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $4000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined. Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00. Copayment for Non-routine Services $0.00. ….
Copayment for Hearing Aids $175.00 to $1225.00. Maximum 2 Hearing Aids every year. Prior Authorization Required for Hearing Aids. Section B - General 18b Note - NOTE ON COST SHARING: Copays will range from a minimum copay of $175 to a maximum of $1 ,225 based on features and style. Copayment for Hearing Aids $175.00 to $1225.00. Maximum 2 Hearing Aids every year. Prior Authorization Required for Hearing Aids. Section B - General 18b Note - NOTE ON COST SHARING: Copays will range from a minimum copay of $175 to a maximum of $1 ,225 based on features and style. Details. Dental care. In-Network: Preventive Dental: Maximum Plan Allowance of $1500.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined. Comprehensive Dental: Copayment for Medicare-covered Benefits $30.00. Oak Street Health Gate City accepts Original Medicare Part A and Part B plans. Also known as traditional Medicare, Original Medicare is a fee-for-service plan, with Medicare paying a portion of the bill for Medicare covered services. Our Greensboro, North Carolina locations accept Part B plans, though some require both Part A and Part B. 2021 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Catawba, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. Original Medicare. Oak Street Health High Point accepts Original Medicare Part A and Part B plans. Also known as traditional Medicare, Original Medicare is a fee-for-service plan, with Medicare paying a portion of the bill for Medicare covered services. Our High Point, North Carolina locations accept Part B plans, though some require both Part ... Copayment for Hearing Aids $175.00 to $1225.00. Maximum 2 Hearing Aids every year. Prior Authorization Required for Hearing Aids. Section B - General 18b Note - NOTE ON COST SHARING: Copays will range from a minimum copay of $175 to a maximum of $1 ,225 based on features and style. We would like to show you a description here but the site won’t allow us. o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 - UD5 Information about you (Please type or print in black or blue ink) Last Name First Name Middle Initial Birth Date Sex ¨ Male ¨ Female Home Phone Number ( ) - Mobile Phone Number ( ) - Social Security Number 2020 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Guilford, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. H5253 041, 533 Medicare Advantage Plans from UnitedHealthcare. Coverage varies by plan. Select a Medicare Advantage Plan below to view details about the coverage it provides: Plan CodePlan Name. H0271:007-0 UnitedHealthcare Medicare Advantage Assure (PPO) H0271:012-0 UnitedHealthcare Medicare Advantage Assure (PPO) H0271:017-0 UnitedHealthcare Medicare ... , Sep 26, 2022 · AARP® Medicare Advantage Plan 2 (HMO-POS) dummy spacing Benefits In-Network Inpatient Hospital Care2 $250 copay per day: days 1-5 $0 copay per day: days 6 and beyond Our plan covers an unlimited number of days for an , Oct 1, 2022 · Wellcare by Health Net for California Post Office Box 10420 Van Nuys, CA 91410 From October 1 – March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. , H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week www.UHCCommunityPlan.com Y0066_SB_H5253_041_000_2022_M. www.UHCCommunityPlan.com , 2021 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Davidson, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. , TTY users 1-877-486-2048. or contact your local SHIP for assistance. Email a copy of the AARP Medicare Advantage Plan 2 (HMO-POS) benefit details. — Medicare Plan Features —. Monthly Premium: $28.00 (see Plan Premium Details below) Annual Deductible: $0. Annual Initial Coverage Limit (ICL): , The UnitedHealthcare Dual Complete (HMO-POS D-SNP) (H5253 - 041) currently has 43,512 members. There are 545 members enrolled in this plan in Orange, North Carolina, and 43,321 members in North Carolina. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars. , Number of Members enrolled in this plan in (H5253 - 041): 23,173 members : Plan’s Summary Star Rating: 4 out of 5 Stars. • Customer Service Rating: 5 out of 5 Stars. • Member Experience Rating: 4 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split as Follows: : Total ... , 2022 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Buncombe, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. , Oak Street Health Gate City accepts Original Medicare Part A and Part B plans. Also known as traditional Medicare, Original Medicare is a fee-for-service plan, with Medicare paying a portion of the bill for Medicare covered services. Our Greensboro, North Carolina locations accept Part B plans, though some require both Part A and Part B. , H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5253_041_000_2023_M , The average monthly premium for Medicare Advantage plans in Wake is $9.46 per month in 2023, though there may be plans available where you live that feature different premiums. Medicare Advantage plans in Wake County have an average Medicare Star Rating of 3.90 in 2023.*. Plans rated four stars or higher are considered top-rated Medicare plans. , 2022 UnitedHealthcare Dual Complete (HMO-POS D-SNP) - H5253-041-0 in NC Plan Benefits Details , The UnitedHealthcare Dual Complete (HMO-POS D-SNP) (H5253 - 041) currently has 34,004 members. There are 441 members enrolled in this plan in Stokes, North Carolina, and 33,873 members in North Carolina. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 4 stars. , Guía de Inscripción 2023 Aproveche todo lo que su plan Medicare Advantage tiene para ofrecer UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 Área de servicio: North Carolina - condados de Alamance, Alexander, Anson, Bertie, Bladen, , We would like to show you a description here but the site won’t allow us. , Copayment for Hearing Aids $175.00 to $1225.00. Maximum 2 Hearing Aids every year. Prior Authorization Required for Hearing Aids. Section B - General 18b Note - NOTE ON COST SHARING: Copays will range from a minimum copay of $175 to a maximum of $1 ,225 based on features and style. , 2023 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO-POS D-SNP) Location: Mecklenburg, North Carolina Click to see other locations. Plan ID: H5253 - 041 - 0 Click to see other plans. Member Services: 1-866-480-1086 TTY users 711. , Guía de Inscripción 2023 Aproveche todo lo que su plan Medicare Advantage tiene para ofrecer UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 Área de servicio: North Carolina - condados de Alamance, Alexander, Anson, Bertie, Bladen, , Feb 22, 2011 · Medicare Advantage & Other Health Plans in Iowa 2023 Iowa Insurance Division 1963 Bell Ave, Suite 100, Des Moines, IA 50315 1-800-351-4664 TTY 1-800-735-2942 , Copayment for Hearing Aids $175.00 to $1225.00. Maximum 2 Hearing Aids every year. Prior Authorization Required for Hearing Aids. Section B - General 18b Note - NOTE ON COST SHARING: Copays will range from a minimum copay of $175 to a maximum of $1 ,225 based on features and style. , The following UnitedHealthCare plans are accepted at Oak Street Health locations. Plan Name. Effective Year. Benefit Package. Summary. AARP Medicare Advantage. 2023. H1944-024. AARP Medicare Advantage. , Feb 22, 2011 · Medicare Advantage & Other Health Plans in Iowa 2023 Iowa Insurance Division 1963 Bell Ave, Suite 100, Des Moines, IA 50315 1-800-351-4664 TTY 1-800-735-2942 , o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 - UD5 Datos del miembro (escriba a máquina o en letra de molde con tinta negra o azul) Apellidos Nombre Inicial del segundo nombre Fecha de nacimiento Sexo ¨ Masculino ¨ Femenino , H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week www.UHCCommunityPlan.com Y0066_SB_H5253_041_000_2022_M , Number of Members enrolled in this plan in (H5253 - 041): 71,322 members : Plan’s Summary Star Rating: 4.5 out of 5 Stars. • Customer Service Rating: 5 out of 5 Stars. • Member Experience Rating: 4 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split as Follows: : Total ... , We would like to show you a description here but the site won’t allow us. , Learn more about the UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 plan for North Carolina. Check eligibility, explore benefits, and enroll today. Hmm … it looks like your browser is out of date. , H5253-041-000 Consulte esta guía y aproveche las coberturas de medicamentos y los servicios de salud que proporciona el plan. Llame a Servicio al Cliente o visite el sitio web para obtener más información sobre el plan. Llamada gratuita 1-855-545-9340, TTY 711 8 a.m. a 8 p.m., hora local, los 7 días de la semana UHCCommunityPlan.com , H5253-041-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-855-545-9340, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week www.UHCCommunityPlan.com Y0066_SB_H5253_041_000_2022_M , Y0066_EOC_H5253_041_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of Coverage , o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5253-041-000 - UD5 Datos del miembro (escriba a máquina o en letra de molde con tinta negra o azul) Apellidos Nombre Inicial del segundo nombre Fecha de nacimiento Sexo ¨ Masculino ¨ Femenino , Copayment for Hearing Aids $175.00 to $1225.00. Maximum 2 Hearing Aids every year. Prior Authorization Required for Hearing Aids. Section B - General 18b Note - NOTE ON COST SHARING: Copays will range from a minimum copay of $175 to a maximum of $1 ,225 based on features and style.