Advantage U for University of Utah Retirees (PPO) includes

• • Hospital and Medical Coverage
  • Prescription Drug Coverage
  • Dental
  • Vision
  • Hearing
  • Fitness
  • Over-the-Counter (OTC)

  • Hospital and Medical Coverage

    Advantage U offers the $0 Premium Advantage U Signature (PPO) plan.

    • $0 Monthly Premium (you must continue to pay your Part B Premium)
    • $0 Copay for In-network Primary Care Physician (PCP)
    • $25 Copay for In-network Specialist Visit
    For a complete listing of benefits please see Summary of Benefits.
    Search In-Network Providers
  • Prescription Drug Coverage

    Our plan features a formulary (or drug list) with a broad number of prescription drugs on Tier 1 and Tier 2, so you can save more.

    See Summary of Benefits for additional prescription drug coverage information.

    Retail Cost-Sharing
    Tier	30-Day Supply	60-Day Supply	100-Day Supply
    Tier 1 (Preferred Generics)	$3 copay	$6 copay	$0 copay
    Tier 2 (Generics)	$10 copay	$20 copay	$20 copay
    Tier 3 (Preferred Brands)	$47 copay	$94 copay	$141 copay
    Tier 4 (Non-Preferred Drugs)	$100 copay	$200 copay	$300 copay
    Tier 5 (Specialty Medications)	29% coinsurance	Not offered	Not Offered

    Senior Savings Model: For Select Insulins, $28 copay for one-month supply is applicable in the Deductible, Initial Coverage and Coverage Gap phases of the Part D Benefit.

    Search Formulary (drug list)

    Search In-Network Pharmacies
  • Dental

    Our plan includes preventive dental coverage with a $0 copay and comprehensive dental coverage for fillings, extractions, crowns, implants or adjunctive periodontal care. Up to $1,500 annual benefit for comprehensive coverage. Authorization rules apply.

    See Summary of Benefits for additional dental benefits.

    Search In-Network Dentists
  • Vision

    We offer a $0 copay for routine vision exam along with coverage for eyeglasses or contact lenses ($120 limit on eyeglasses and contacts).

    See Summary of Benefits for additional vision benefits.

    Search Eye Doctors

  • Hearing

    Our plan includes a $0 copay for routine hearing exams through TruHearing along with hearing aid coverage.

    See Summary of Benefits for additional hearing benefits.

  • Fitness

    Enjoy a Fitness Center Membership to participating fitness centers and choose to receive Home Fitness Kit.

    You can visit a participating fitness center near you. You also have access to a variety of Home Fitness Kits.

    The Silver&Fit® program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). Silver &Fit® is a federally registered trademark of ASH and used with permission herein. Kits are subject to change. Participating facilities and fitness chains may vary by location and are subject to change.

  • Over-the-Counter (OTC)

    With our plan, members receive a $50 allowance each quarter to use for the purchase of select OTC products.

• • Hospital and Medical Coverage
  • Prescription Drug Coverage
  • Dental
  • Vision
  • Hearing
  • Fitness
  • Over-the-Counter (OTC)

  • Hospital and Medical Coverage

    Advantage U offers the $0 Premium Advantage U Signature (PPO) plan.

    • $0 Monthly Premium (you must continue to pay your Part B Premium)
    • $0 Copay for In-network Primary Care Physician (PCP)
    • $25 Copay for In-network Specialist Visit
    For a complete listing of benefits please see Summary of Benefits.
    Search In-Network Providers
  • Prescription Drug Coverage

    Our plan features a formulary (or drug list) with a broad number of prescription drugs on Tier 1 and Tier 2, so you can save more.

    See Summary of Benefits for additional prescription drug coverage information.

    Retail Cost-Sharing
    Tier	30-Day Supply	60-Day Supply	100-Day Supply
    Tier 1 (Preferred Generics)	$3 copay	$6 copay	$0 copay
    Tier 2 (Generics)	$10 copay	$20 copay	$20 copay
    Tier 3 (Preferred Brands)	$47 copay	$94 copay	$141 copay
    Tier 4 (Non-Preferred Brands)	$100 copay	$200 copay	$300 copay
    Tier 5 (Specialty Medications)	29% coinsurance	Not offered	Not Offered

    Senior Savings Model: For Select Insulins, $28 copay for 30-day supply is applicable in the Deductible, Initial Coverage and Coverage Gap phases of the Part D Benefit.

    Search Formulary (drug list)

    Search In-Network Pharmacies
  • Dental

    Our plan includes preventive dental coverage with a $0 copay and comprehensive dental coverage for fillings, extractions, crowns, implants or adjunctive periodontal care. Up to $1,500 annual benefit for comprehensive coverage. Authorization rules apply.

    See Summary of Benefits for additional dental benefits.

    Search In-Network Dentists
  • Vision

    We offer a $0 copay for routine vision exam along with coverage for eyeglasses or contact lenses ($120 limit on eyeglasses and contacts).

    See Summary of Benefits for additional vision benefits.

    Search Eye Doctors

  • Hearing

    Our plan includes a $0 copay for routine hearing exams through TruHearing along with hearing aid coverage.

    See Summary of Benefits for additional hearing benefits.

  • Fitness

    Enjoy a Fitness Center Membership to participating fitness centers and choose to receive Home Fitness Kits.

    You can visit a participating fitness center near you. You also have access to a variety of Home Fitness Kits.

    The Silver&Fit® program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). Silver &Fit® is a federally registered trademark of ASH and used with permission herein. Kits are subject to change. Participating facilities and fitness chains may vary by location and are subject to change.

  • Over-the-Counter (OTC)

    With our plan, members receive a $30 allowance each quarter to use for the purchase of select OTC products.