Group UCare for Seniors

PEIP Retirees

Effective January 1, 2012 through December 31, 2012

Benefit Category

/

Group UCare for Seniors

High Rx Option /

Group UCare for Seniors

Low Rx Option

Premium

/ $239.00 / $144.00

Prescription Drug Coverage

Up to a 34-day supply for one co-pay
102-day supply through some participating local pharmacies and mail-order for 2 co-pays / $10 co-pay - generic
$30 co-pay preferred brand name
$60 co-pay other brand name
25% co-pay specialty drugs
Unlimited coverage; covers through the prescription drug gap or the “donut hole.” / $10 co-pay - generic
$30 co-pay preferred brand name
$60 co-pay other brand name
25% co-pay specialty drugs.
After your total yearly drug costs reach $2,930 you pay 100% until you pay $4,700 out of pocket. Generics continue to be covered after the $10 co-pay Medicare catastrophic Rx coverage begins at that time.

Preventive Care (ie: physicals, eye and hearing exams, flu shots)

/ 100% coverage / 100% coverage

Office Visits

/ $15 co-payment per visit / $15 co-payment per visit
In-PatientHospital / 100% coverage after a
$100 co-pay / 100% coverage after a
$100 co-pay
Emergency Room Services
(In and out of service area-worldwide) / $50 co-pay per hospital emergency room visit; 100% coverage thereafter. If admitted, $50 co-pay is waived. Coverage is worldwide. / $50 co-pay per hospital emergency room visit; 100% coverage thereafter. If admitted, $50 co-pay is waived. Coverage is worldwide.
Preventive Dental / 100% coverage:
3 cleanings per year / 100% coverage:
3 cleanings per year
Vision Care and Eyewear / 100% coverage for eye exams
Eyewear: $75 annual allowance toward the purchase of new frames and lenses. / 100% coverage for eye exams Eyewear: $75 annual allowance toward the purchase of new frames and lenses
Point of Service
(Non-Emergency, Non-Network Providers) / 80% coverage – see Summary of Benefits for details / 80% coverage – see Summary of Benefits for deatils

Please see reverse side for more information

  • Service area includes the entire State of Minnesota and 26 counties in Western Wisconsin.
  • Enrollees must carry both Parts A and B of Medicare; automatic enrollment in Part D.
  • Comprehensive Dental Plan available for additional $21 per member per month (available for both options). UCare will bill you at home for the Dental Plan.
  • Worldwide emergency coverage for up to 6 months out-of-area.
  • UCan! Activity Network - health club membership discounts, fitness classes, at-home exercise kit.
  • See Group UCare for Seniors Summary of Benefits for full plan description
  • Web site:

Contact the Group UCare for SeniorsSales Team at:

612-676-6900 or toll-free at 1-877-598-6574