AARP Medicare Advantage Giveback from UHC TC-4 (HMO-POS)

H5253 - 121 - 0

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AARP Medicare Advantage Giveback from UHC TC-4 (HMO-POS) is a Medicare Advantage Plan by UnitedHealthcare.

This page features plan details for 2025 AARP Medicare Advantage Giveback from UHC TC-4 (HMO-POS) H5253 – 121 – 0 available in Select Counties in Tennessee and Virginia.

Locations

AARP Medicare Advantage Giveback from UHC TC-4 (HMO-POS) is offered in the following locations.

Anderson County, Tennessee

Bedford County, Tennessee

Benton County, Tennessee

Click to see more locations

Plan Overview

AARP Medicare Advantage Giveback from UHC TC-4 (HMO-POS) offers the following coverage and cost-sharing.

Insurer:	UnitedHealthcare
Health Plan Deductible:	–
MOOP:	$6,300.00 in-network
Drugs Covered:	Yes

Ready to sign up for AARP Medicare Advantage Giveback from UHC TC-4 (HMO-POS) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.

AARP Medicare Advantage Giveback from UHC TC-4 (HMO-POS) qualifies for a monthly Medicare Give Back Benefit of $105.00.

Premium Reduction:

$105.00

Premium Breakdown

AARP Medicare Advantage Giveback from UHC TC-4 (HMO-POS) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$185.00	$0.00	$0.00	$105.00	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

AARP Medicare Advantage Giveback from UHC TC-4 (HMO-POS) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$495.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$0.00	$0.00

Initial Coverage Phase

After you pay your $495.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic
2) Generic	$14.00 Copay
3) Preferred Brand	$47.00 Copay
4) Non-Preferred Drug	$100.00 Copay	$100.00 Copay	$100.00 Copay
5) Specialty Tier		27.00% Coinsurance	27.00% Coinsurance

60 Day

90 Day

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

AARP Medicare Advantage Giveback from UHC TC-4 (HMO-POS) also provides the following benefits.

Cardiac and Pulmonary Rehabilitation Services

Additional Cardiac Rehabilitation Services

Copay: $0.00

Additional Pulmonary Rehabilitation Services

Copay: $0.00

Additional Intensive Cardiac Rehabilitation Services

Copay: $15.00

Additional Supervised Exercise Therapy for Peripheral Artery Disease

Copay: $15.00
Authorization Required: Yes
Referral Required: No

Durable Medical Equipment, Prosthetics/Orthotics, and Medical Supplies

Prosthetics/Medical Supplies

Authorization Required: Yes
Preferred Vendors: No

Prosthetics/Orthotics – Orthotic Devices

Coinsurance: 20%

Prosthetics/Orthotics – Orthotic Devices

Coinsurance: 20%

Medical Supplies – Medical/Surgical Supplies

Coinsurance: 20%

Medical Supplies – Medical/Surgical Supplies

Copay: $0.00
Specified Manufacturers: Yes
Limits Apply: Yes

Emergency and Urgent Care Services

Urgently Needed Services

Copay: $125.00
Enhanced Benefits: Worldwide Emergency Coverage; Worldwide Urgent Coverage; Worldwide Emergency Transportation
Waivers if Admitted: Yes

Worldwide Emergency Transportation

Copay: $0.00

Eye Exams and Eye Wear Services

Eye Exams

Enhanced Benefits: Routine Eye Exams

Routine Eye Exams

Limits Apply: No

Eyewear

Copay: $0.00
Authorization Required: Yes
Referral Required: No
Enhanced Benefits: Contact lenses; Eyeglass lenses; Eyeglass frames

Contact Lenses

Limits Apply: Yes

Eyeglass Lenses

Limits Apply: No

Eyeglass Frames

Copay: $0.00
Authorization Required: No
Limits Apply: No

Health Care Professional Services

Opioid Treatment Program Services

Copay: $0.00

Chiropractic Services

Copay: $20.00
Authorization Required: Yes
Referral Required: No

Psychiatric Services – Inpatient Care

Copay: $0.00 – $25.00

Psychiatric Services – Outpatient Care

Copay: $15.00

Podiatry Services

Enhanced Benefits: Routine Foot Care

Podiatry Services

Limits Apply: No

PT and SP Services

Copay: $35.00

Additional Telehealth Services

Authorization Required: No

Hearing Exams and Hearing Aids Services

Hearing Exams

Enhanced Benefits: Routine Hearing Exams

Routine Hearing Exams

Limits Apply: No

Hearing Aids

Copay: $0.00
Authorization Required: Yes
Referral Required: No
Enhanced Benefits: Hearing Aids (all types)

Hearing Aids (All Types)

Copay: $199.00 – $1249.00
Authorization Required: No
Limits Apply: No

Home Health Services

Copay: $0.00

Home Health Services

Authorization Required: Yes
Referral Required: No

Inpatient Hospital Acute Services

Inpatient Hospital-Acute

Enhanced Benefits: Additional Days

Inpatient Acute Additional Days

Limits Apply: Yes

Inpatient Hospital-Acute

Authorization Required: Yes
Referral Required: No
Day Interval 1: $375.00 (Days 1 – 5)
Day Interval 2: $0.00 (Days 6 – 90)
Day Interval 1: $0.00 (Days 1 – 5)

Inpatient Hospital Psychiatric Services

Inpatient Hospital-Psychiatric

Authorization Required: Yes
Referral Required: No
Day Interval 1: $375.00 (Days 1 – 5)
Day Interval 2: $0.00 (Days 6 – 90)

Medicare Part B Prescription Drugs

Medicare Part B Drugs – Tier 2

Coinsurance: 0% – 20%

Medicare Part B Drugs – Tier 3

Coinsurance: 0% – 20%

Medicare Part B Drugs – Tier 1

Coinsurance: 0% – 20%
Authorization Required: Yes

Out-of-Network Data for PPO Plans

Outpatient Clinical, Diagnostic, and Therapeutic Radiology Services

Outpatient Diagnostic Procedures/Tests

Copay: $25.00

Outpatient Lab Services

Copay: $0.00
Authorization Required: Yes
Referral Required: No

Outpatient Therapeutic Radiology

Coinsurance: 20%

Outpatient Diagnostic Radiology

Copay: $0.00 – $150.00

Outpatient X-Ray Services

Copay: $15.00

Outpatient Hospital, ASC, Substance Abuse, and Cardiac Rehabilitation Services

Outpatient Hospital Services – General

Copay: $0.00 – $375.00

Outpatient Hospital Services – Observation

Copay: $375.00
Authorization Required: Yes
Referral Required: No

Outpatient Blood Services – Type 1

Copay: $0.00 – $25.00

Outpatient Blood Services – Type 2

Copay: $15.00

Partial Hospitalization Services

Partial Hospitalization

Copay: $55.00
Authorization Required: Yes
Referral Required: No

Preventive Services (Health Education, Immunizations, Routine Physicals, Pap/Pelvic Exams)

Kidney Disease Education Services

Authorization Required: No
Referral Required: No

Other Medicare-covered Preventive Services

Copay: $0.00

Other Defined Supplemental Benefits

Enhanced Benefits: 14c4: Fitness Benefit*;

14c4(NMC)

Copay: $0.00

Diabetes Self-Management Training – Level 1

Copay: $0.00

Diabetes Self-Management Training – Level 2

Copay: $0.00

Diabetes Self-Management Training – Level 3

Copay: $0.00

Diabetes Self-Management Training – Level 4

Copay: $0.00

Diabetes Self-Management Training – Level 5

Copay: $0.00
Authorization Required: No
Referral Required: No

Renal Dialysis Services

Dialysis Services

Coinsurance: 20%
Authorization Required: Yes
Referral Required: No

Skilled Nursing Facility (SNF) Services

SNF Medicare-covered stay

Authorization Required: Yes
Referral Required: No
Day Interval 1: $0.00 (Days 1 – 20)
Day Interval 2: $203.00 (Days 21 – 100)

Ready to sign up for AARP Medicare Advantage Giveback from UHC TC-4 (HMO-POS) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Tier	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic
2) Generic	$42.00 Copay		$42.00 Copay
3) Preferred Brand	$141.00 Copay	$131.00 Copay	$141.00 Copay
4) Non-Preferred Drug
5) Specialty Tier