Enrollment Guide 2023 Take advantage of all your Medicare Advantage plan has to offer UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H0169-002-000 Service area: Missouri - Adair, Andrew, Atchison, Audrain, Barry, Barton, Bates, Benton, Bollinger,Number of Members enrolled in this plan in (H0169 - 004): 1,480 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 ...Información sobre proveedores UnitedHealthcare Dual Complete® (HMO-POS D-SNP) Aprovechará los beneficios adicionales de su plan si usa los proveedores indicados a continuaciónThe UnitedHealthcare Dual Complete (HMO SNP) (H0169 - 002) currently has 8,801 members. There are 28 members enrolled in this plan in Barry, Missouri, and 8,695 members in Missouri. Prescription Drug Coverage: Deductible, Cost-sharing, Formulary: This plan has a $415 deductible. So, you are 100% responsible for the first $415 in medication costs. Number of Members enrolled in this plan in (H0169 - 002): 14,549 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 ...Vendor Information UnitedHealthcare Dual Complete® (HMO-POS D-SNP) Take advantage of your additional plan benefits by using the providers below or contacting 2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H0169-002-000; 2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H0169-008-000; 2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H0271-029-000; 2023 Medicare Advantage Quick Reference Guide - Missouri-Illinois POS and PPO PlansUnitedHealthcare Dual Complete® (HMO-POS D-SNP) UnitedHealthcare Dual Complete® Select (HMO-POS D-SNP) Complete Drug List (Formulary) 2023 Important notes: This document has information about the drugs covered by this plan.Jan 1, 2023 · 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H0169_002_000_2023_M Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of Coverage (EOC) for complete list of covered services, limitations and exclusions. Y0066_EOC_H0169_002_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of Coverage H0169-002-000 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 1-844-560-4944, TTY 711 8 a.m. a 8 p.m., hora local, los 7 días de la semana UHCCommunityPlan.com This page features plan details for 2023 UnitedHealthcare Dual Complete (HMO-POS D-SNP) H0169 – 002 – 0 available in Select Counties in Missouri. IMPORTANT : This page has been updated with plan and premium data for 2023. UnitedHealthcare - H0169 For 2023, UnitedHealthcare - H0169 received the following Star Ratings from Medicare: Overall Star Rating: 4.5 stars Health Services Rating: 4 stars Drug Services Rating: 4 stars Every year, Medicare evaluates plans based on a 5-star rating system. Why Star Ratings are Important Medicare rates plans on their health and ... Sep 26, 2022 · H0169-008-000 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 1-844-560-4944, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H0169_008_000_2023_M 2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H0169-002-000 Subject UnitedHealthcare Dual Complete additional benefit overview for health care professionals. H0169-002-000 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 1-844-560-4944, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week www.UHCCommunityPlan.com Y0066_SB_H0169_002_000_2022_M. www.UHCCommunityPlan.comH0169-002-000 MO99MODSNPF MO99MODSNPP MO99MODSNPQ ... H0169-008-000 MO99MODSNP3F MO99MODSNP3P MO99MODSNP3Q UnitedHealthcare Dual Complete® Choice (PPO D-SNP) 2019 Medicare Part D Contract ID/Plan ID Search. Q1Medicare.com providing detailed information on the Medicare Part D program for every state, including selected Medicare Part D plan features and costs organized by State.The UnitedHealthcare Dual Complete (HMO SNP) (H0169 - 002) currently has 8,801 members. There are 28 members enrolled in this plan in Barry, Missouri, and 8,695 members in Missouri. Prescription Drug Coverage: Deductible, Cost-sharing, Formulary: This plan has a $415 deductible. So, you are 100% responsible for the first $415 in medication costs. 2020 UnitedHealthcare Dual Complete (HMO D-SNP) - H0169-002-0 in MO Plan Benefits Explained UnitedHealthcare Dual Complete (HMO-POS D-SNP) H0169-002-000 2023 Plan Details and Costs Learn More about UnitedHealthcare UnitedHealthcare Dual Complete (HMO-POS D-SNP) Plan Details, including how much you can expect to pay for coinsurance, deductibles, premiums and copays for various services covered by the plan. H0169-002-000 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 1-844-560-4944, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H0169_002_000_2023_MThe UnitedHealthcare Dual Complete (HMO D-SNP) (H0169 - 001) currently has 14,992 members. There are 15 members enrolled in this plan in Hancock, Iowa, and 14,934 members in Iowa. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars. o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H0169-002-000 - 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 Number2022 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO D-SNP) Location: Pulaski, Missouri Click to see other locations. Plan ID: H0169 - 002 - 0 Click to see other plans. Member Services: 1-844-368-6886 TTY users 711.As an Arkansas Blue Medicare member, you’ll be eligible to earn valuable rewards for getting exams, preventive screenings, tests and completing other health-related activities. Comprehensive dental benefits. $0 copay for 1 routine hearing exam per year. $699/$999 copay per hearing aid (2 per year) Please see plan documents for more details. Number of Members enrolled in this plan in (H0169 - 002): 24,875 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 ...2021 UnitedHealthcare (H0169) Star Rating Details; UnitedHealthcare Dual Complete (HMO D-SNP) (H0169-002-0) Benefit Details The UnitedHealthcare Dual Complete (HMO D-SNP) (H0169-002-0) in Lafayette, MO: CMS MA Region 15 which includes: MO Plan Monthly Premium: $30.50 Deductible: $445: Star Rating Category & Measures: 2021: 20202018 UnitedHealthcare Dual Complete (HMO SNP) - H0169-002-0 in MO Plan Benefits DetailsAs an Arkansas Blue Medicare member, you’ll be eligible to earn valuable rewards for getting exams, preventive screenings, tests and completing other health-related activities. Comprehensive dental benefits. $0 copay for 1 routine hearing exam per year. $699/$999 copay per hearing aid (2 per year) Please see plan documents for more details. Number of Members enrolled in this plan in (H0169 - 002): 38,511 members : Plan’s Summary Star Rating: 4.5 out of 5 Stars. • Customer Service Rating: Insufficient data to rate this plan. • Member Experience Rating: 5 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split ...2021 UnitedHealthcare (H0169) Star Rating Details; UnitedHealthcare Dual Complete (HMO D-SNP) (H0169-002-0) Benefit Details The UnitedHealthcare Dual Complete (HMO D-SNP) (H0169-002-0) in Lafayette, MO: CMS MA Region 15 which includes: MO Plan Monthly Premium: $30.50 Deductible: $445: Star Rating Category & Measures: 2021: 2020H0169-002 -000 Monthly premium: $ 0.00 * * Your costs may be as low as $0, depending on your level of Medicaid eligibility. Our plan is a Medicare Advantage HMO Plan (HMO stands for Health Maintenance Organization) with a Point-of-Service (POS) option approved by Medicare and run by a private company. Number of Members enrolled in this plan in (H0169 - 002): 38,511 members : Plan’s Summary Star Rating: 4.5 out of 5 Stars. • Customer Service Rating: Insufficient data to rate this plan. • Member Experience Rating: 5 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split ... The UnitedHealthcare Dual Complete (HMO D-SNP) (H0169 - 002) currently has 18,440 members. There are 455 members enrolled in this plan in Clay, Missouri, and 18,325 members in Missouri. 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 (H0169 - 002): 38,511 members : Plan’s Summary Star Rating: 4.5 out of 5 Stars. • Customer Service Rating: Insufficient data to rate this plan. • Member Experience Rating: 5 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split ... The UnitedHealthcare Dual Complete (HMO SNP) (H0169 - 002) currently has 8,801 members. There are 28 members enrolled in this plan in Barry, Missouri, and 8,695 members in Missouri. Prescription Drug Coverage: Deductible, Cost-sharing, Formulary: This plan has a $415 deductible. So, you are 100% responsible for the first $415 in medication costs.Y0066_EOC_H0169_001_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of Coverage2021 Medicare Advantage Plan Benefit Details for the UnitedHealthcare Dual Complete (HMO D-SNP) - H0169-002-0 This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans. 2022 UnitedHealthcare Dual Complete (HMO D-SNP) - H0169-002-0 in MO Plan Benefits DetailsThe UnitedHealthcare Dual Complete (HMO SNP) (H0169 - 002) currently has 8,801 members. There are 28 members enrolled in this plan in Barry, Missouri, and 8,695 members in Missouri. Prescription Drug Coverage: Deductible, Cost-sharing, Formulary: This plan has a $415 deductible. So, you are 100% responsible for the first $415 in medication costs. 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.As an Arkansas Blue Medicare member, you’ll be eligible to earn valuable rewards for getting exams, preventive screenings, tests and completing other health-related activities. Comprehensive dental benefits. $0 copay for 1 routine hearing exam per year. $699/$999 copay per hearing aid (2 per year) Please see plan documents for more details.The UnitedHealthcare Dual Complete (HMO D-SNP) (H0169 - 002) currently has 18,440 members. There are 286 members enrolled in this plan in St. Francois, Missouri, and 18,325 members in Missouri. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars.UnitedHealthcare Dual Complete® (HMO-POS D-SNP) UnitedHealthcare Dual Complete® Select (HMO-POS D-SNP) Complete Drug List (Formulary) 2023 Important notes: This document has information about the drugs covered by this plan. The UnitedHealthcare Dual Complete LP1 (HMO-POS D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $0 per year. Coverage. Cost. 30 day supply. 60 day supply. 90 day supply. Coverage & Cost. 30 day supply. 60 day supply.2023 Evidence of Coverage for UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) Table of Contents Questions? Call Customer Service at 1-866-842-4968, TTY 711, 8am-8pm: 7 Days Oct- Y0066_ANOC_H0169_002_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 ... 2022 UnitedHealthcare Dual Complete (HMO D-SNP) - H0169-002-0 in MO Star Rating DetailsMedicare Advantage & Other Health Plans in Iowa 2023 Iowa Insurance Division 1963 Bell Ave, Suite 100, Des Moines, IA 50315 1-800-351-4664 TTY 1-800-735-2942VDOMDHTMLad>. 301 Moved Permanently. 301 Moved Permanently. Microsoft-Azure-Application-Gateway/v2. The UnitedHealthcare Dual Complete (HMO SNP) (H0169 - 002) currently has 8,801 members. There are 28 members enrolled in this plan in Barry, Missouri, and 8,695 members in Missouri. Prescription Drug Coverage: Deductible, Cost-sharing, Formulary: This plan has a $415 deductible. So, you are 100% responsible for the first $415 in medication costs.UnitedHealthcare - H0169 For 2023, UnitedHealthcare - H0169 received the following Star Ratings from Medicare: Overall Star Rating: 4.5 stars Health Services Rating: 4 stars Drug Services Rating: 4 stars Every year, Medicare evaluates plans based on a 5-star rating system. Why Star Ratings are Important Medicare rates plans on their health and ...The UnitedHealthcare Dual Complete (HMO D-SNP) (H0169 - 001) currently has 14,992 members. There are 15 members enrolled in this plan in Hancock, Iowa, and 14,934 members in Iowa. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars. H0169-001-000 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 1-844-560-4944, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H0169_001_000_2023_MEnrollment Guide 2023 Take advantage of all your Medicare Advantage plan has to offer UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H0169-002-000 Service area: Missouri - Adair, Andrew, Atchison, Audrain, Barry, Barton, Bates, Benton, Bollinger,2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H0169-002-000; 2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H0169-008-000; 2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H0271-029-000; 2023 UnitedHealthcare Dual Complete Plan Frequently Asked Questions H0169-002-000UnitedHealthcare Dual Complete® (HMO-POS D-SNP) UnitedHealthcare Dual Complete® Select (HMO-POS D-SNP) Complete Drug List (Formulary) 2023 Important notes: This document has information about the drugs covered by this plan.2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H0169-002-000 Subject UnitedHealthcare Dual Complete additional benefit overview for health care professionals. UnitedHealthcare offers UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H0169-002-000 plans for Missouri and eligible counties. This plan gives you a choice of doctors and hospitals. Learn about steps to enroll. VDOMDHTMLad>. 301 Moved Permanently. 301 Moved Permanently. Microsoft-Azure-Application-Gateway/v2.Información sobre proveedores UnitedHealthcare Dual Complete® (HMO-POS D-SNP) Aprovechará los beneficios adicionales de su plan si usa los proveedores indicados a continuaciónH0169-002-000 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 1-844-560-4944, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H0169_002_000_2023_MThe UnitedHealthcare Dual Complete (HMO D-SNP) (H0169 - 002) currently has 18,440 members. There are 286 members enrolled in this plan in St. Francois, Missouri, and 18,325 members in Missouri. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars. o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H0169-002-000 - 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 Number2019 Medicare Part D Contract ID/Plan ID Search. Q1Medicare.com providing detailed information on the Medicare Part D program for every state, including selected Medicare Part D plan features and costs organized by State.H0169-002-000 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 1-844-560-4944, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week www.UHCCommunityPlan.com Y0066_SB_H0169_002_000_2022_M. www.UHCCommunityPlan.comUnitedHealthcare Dual Complete Plan 1 (HMO-POS D-SNP) covers a range of additional benefits. Learn more about UnitedHealthcare Dual Complete Plan 1 (HMO-POS D-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B). Diabetes supplies, training, nutrition therapy and monitoring. The UnitedHealthcare Dual Complete (HMO D-SNP) (H0169 - 002) currently has 18,440 members. There are 455 members enrolled in this plan in Clay, Missouri, and 18,325 members in Missouri. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars. 2022 UnitedHealthcare Dual Complete (HMO D-SNP) - H0169-002-0 in MO Star Rating Details o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H0169-002-000 - 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 ¨ FemeninoA federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. 7500 Security Boulevard, Baltimore, MD 212442022 UnitedHealthcare Dual Complete (HMO D-SNP) - H0169-002-0 in MO Plan Benefits DetailsWe would like to show you a description here but the site won’t allow us.Jan 1, 2023 · H0169-001-000 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 1-844-560-4944, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H0169_001_000_2023_M Number of Members enrolled in this plan in (H0169 - 002): 38,511 members : Plan’s Summary Star Rating: 4.5 out of 5 Stars. • Customer Service Rating: Insufficient data to rate this plan. • Member Experience Rating: 5 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split ... 4.5 out of 5 stars* for plan year 2023. $0.00 Monthly Premium. UnitedHealthcare Dual Complete (HMO-POS D-SNP) is a HMO-POS D-SNP Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare. Plan ID: H0169-002-000.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 1-800-735-29422023 UnitedHealthcare Dual Complete Plan Benefit Flyer H0169-002-000 Subject UnitedHealthcare Dual Complete additional benefit overview for health care professionals.
VDOMDHTMLad>. 301 Moved Permanently. 301 Moved Permanently. Microsoft-Azure-Application-Gateway/v2. . Michigan daily lottery 3 and 4 digit midday
Vendor Information UnitedHealthcare Dual Complete® (HMO-POS D-SNP) Take advantage of your additional plan benefits by using the providers below or contacting 2020 UnitedHealthcare Dual Complete (HMO D-SNP) - H0169-002-0 in MO Plan Benefits Explained UnitedHealthcare - H0169 For 2023, UnitedHealthcare - H0169 received the following Star Ratings from Medicare: Overall Star Rating: 4.5 stars Health Services Rating: 4 stars Drug Services Rating: 4 stars Every year, Medicare evaluates plans based on a 5-star rating system. Why Star Ratings are Important Medicare rates plans on their health and ...The UnitedHealthcare Dual Complete (HMO D-SNP) (H0169 - 001) currently has 14,992 members. There are 15 members enrolled in this plan in Hancock, Iowa, and 14,934 members in Iowa. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars.o UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H0169-002-000 - 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 ¨ FemeninoAs an Arkansas Blue Medicare member, you’ll be eligible to earn valuable rewards for getting exams, preventive screenings, tests and completing other health-related activities. Comprehensive dental benefits. $0 copay for 1 routine hearing exam per year. $699/$999 copay per hearing aid (2 per year) Please see plan documents for more details.The UnitedHealthcare Dual Complete (HMO D-SNP) (H0169 - 002) currently has 18,440 members. There are 286 members enrolled in this plan in St. Francois, Missouri, and 18,325 members in Missouri. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars. 2023 Evidence of Coverage for UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) Table of Contents Questions? Call Customer Service at 1-866-842-4968, TTY 711, 8am-8pm: 7 Days Oct- 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H0169_002_000_2023_M Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of Coverage (EOC) for complete list of covered services, limitations and exclusions.Enrollment Guide 2023 Take advantage of all your Medicare Advantage plan has to offer UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H0169-002-000 Service area: Missouri - Adair, Andrew, Atchison, Audrain, Barry, Barton, Bates, Benton, Bollinger,Learn more about the UnitedHealthcare Dual Complete® Select (HMO-POS D-SNP) H0169-006-000 plan for Nebraska. Check eligibility, explore benefits, and enroll today.H0169-002-000 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 1-844-560-4944, TTY 711 8 a.m. a 8 p.m., hora local, los 7 días de la semana UHCCommunityPlan.com2022 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete (HMO D-SNP) Location: Pulaski, Missouri Click to see other locations. Plan ID: H0169 - 002 - 0 Click to see other plans. Member Services: 1-844-368-6886 TTY users 711.Y0066_EOC_H0169_002_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of CoverageMaximum 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..
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