2026

Plan Guide

Eaton

UnitedHealthcare® Group Medicare Advantage (PPO)

Group Number:

13354

Effective:

January 1, 2026 through December 31, 2026

UnitedHealthcare 2026 Plan Guide — page 2

With the UnitedHealthcare Group

Medicare Advantage (PPO)

plan,

you get more

Your former employer or plan sponsor has selected UnitedHealthcare® to provide

health care

and

prescription drug coverage to their Medicare-eligible retirees. With

this plan, you'll enjoy an easier

than ever Medicare experience.

You’ve earned it.

Read through this Plan

Guide to get to know your new plan

The guide includes:

• A description of the plan and how it works

•

Information about benefits, programs and services, and how much they cost

•

Information about covered drugs and how much they cost

• What you can expect after you're enrolled in the plan

Please keep this Plan Guide. It has information that will be helpful once you

become a member.

You can also get plan information at

retiree.uhc.com/EatonMAPD

. Select the

Chat now

button to connect with one of our knowledgeable Customer Service

Advocates. Or, use the Group Number on the front cover of this book to

access plan materials online.

How to enroll

If you want to enroll in this plan, follow the instructions from your former

employer or plan sponsor. They will forward your enrollment information to us.

Take control of your health

We can help you get access to the care you need when you need it. Let us

help you find ways to save money on your health care so you can focus on

what matters most to you.

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Visit

retiree.uhc.com/EatonMAPD

and select the

Chat

now

button

Call toll-free

1-866-859-0849,

TTY

711

8 a.m.-8 p.m. local time, Monday-Friday

UnitedHealthcare 2026 Plan Guide — page 3

More than health insurance

With this UnitedHealthcare Group Medicare Advantage (PPO) plan you get medical and

prescription drug coverage and so much more. More benefits. More savings. More experience.

More choices. More convenience.

Here’s just some of what this plan offers

copay

for home-delivered meals,

transportation to medical

appointments and the pharmacy, and

non-medical personal care to assist

with daily activities after a hospital or

skilled nursing facility stay

Earn rewards

to spend on eligible

items like gifts, clothing, groceries and

Free delivery with Optum® Home

Delivery Pharmacy

for prescriptions

you take regularly*

Free standard gym membership

participating locations

Free Optum® HouseCalls visit

from

one of our licensed health care

practitioners

$0 copay for a hearing exam

and

$500 allowance

to spend on a broad

selection of hearing aids for both ears

every 3 years

Virtual doctor and behavioral health

visits

using your computer, tablet or

smartphone – anytime, day or night

A large network of providers

through

our Medicare National Network

Special programs to help you

if you

are living with a chronic disease, like

diabetes or heart disease, or other

complex health needs

Free diabetic supplies

like needles

and test strips

Review the Summary

of Benefits in this guide

for more details

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*Optum® Home Delivery Pharmacy and Optum Rx

affiliates are not available in all areas.

UnitedHealthcare 2026 Plan Guide — page 4

sponsored Medicare Advantage plan.

Here’s how this PPO plan works

Get care from providers in or out-of-

network

as long as they accept

Medicare and the plan

You don’t need a referral to see a

specialist or other provider

Select a

primary care provider

(PCP)

to oversee and help manage your

care

It’s not required by the plan, but it’s

very beneficial for your long-term

health and well-being.

You pay a standard copay or

coinsurance, or $0 in some cases,

to see a provider in

or out-

of-network

We work closely with our network

(contracted) providers to make sure

they have access to resources and

tools to help them work with you for

better health outcomes.

This plan has separate maximum

annual out-of-pocket amounts for

medical and prescription drugs

If you reach your plan’s medical limit,

the plan will pay 100% of your

Medicare-covered services for the rest

of the plan year. After you and others

on your behalf have paid a combined

total of $2,100 for your prescription

drugs, you won’t pay anything for your

Medicare-covered Part D drugs for the

rest of the calendar year.

Emergency and urgently needed

services are covered anywhere in

the world

This plan includes prescription drug

coverage for thousands of brand

name and generic drugs

To search for a network provider or pharmacy, visit

retiree.uhc.com/EatonMAPD

You can also view the plan

Drug List (Formulary) to see what drugs are covered and if

there are any restrictions.

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Scan this

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the Drug List

UnitedHealthcare 2026 Plan Guide — page 5

More ways to learn

about your plan

It’s important that you understand your plan and what

benefits are covered. You can find the Drug List, Provider

and Pharmacy directories and more at

retiree.uhc.com/

EatonMAPD

You’re eligible to

enroll in this plan if

you:

Are entitled to Medicare

Part A and enrolled in

Medicare Part B.

Continue to pay your

Part B premium (unless

it’s paid for you).

Review the online Drug List to see what prescription

drugs are covered

And what drug tier they are in. Generally, the lower the

drug tier, the less you’ll pay.

Review the online Provider Directory to see if your

providers are in the network

It's okay if they’re not. This plan allows you to see out-of-

network providers at the same cost share as long as they

accept Medicare and the plan.

Review the online Pharmacy Directory to see what

pharmacies are in our network

If your pharmacy is not in the network, you will need to

select a new network pharmacy to pay your planʼs lowest

cost for prescription drugs.

Review the Summary of Benefits in this guide to see

how much you’ll pay for medical services and

prescription drugs

You can also review the Summary of Benefits online.

If you’re not sure if you are enrolled in Medicare Part B, check

with Social Security at ssa.gov/locator or call 1-800-772-1213,

TTY 1-800-325-0778, 8 a.m.–7 p.m., Monday–Friday, or call

your local office.

You may be disenrolled from this plan if you stop paying your

Medicare Part B premium.

Remember:

If you drop or are disenrolled from your group-sponsored retiree

coverage, you may not be able to re-enroll. Limitations and restrictions vary by

former employer or plan sponsor.

Y0066_GRP_GTKYP_2026_C

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UnitedHealthcare 2026 Plan Guide — page 6

Summary of

Benefits 2026

UnitedHealthcare® Group Medicare Advantage (PPO)

Group Name

(Plan Sponsor): Eaton

Group Number: 13354

H2001-816-000

Look inside to learn more about the plan and the health and drug services

it covers.

retiree.uhc.com/EatonMAPD

Toll-free

1-866-859-0849

TTY

711

8 a.m.-8 p.m. local time, Monday-Friday

Y0066_SB_H2001_816_000_2026_M

UnitedHealthcare 2026 Plan Guide — page 7

Summary of Benefits

January 1, 2026 - December 31, 2026

This is a summary of what we cover and what you pay. Review the Evidence of Coverage (EOC) for

a complete list of covered services, limitations and exclusions. You can call Customer Service if

you want a copy of the EOC or need help. When you enroll in the plan, you will get more

information on how to view your plan details online.

UnitedHealthcare® Group Medicare Advantage (PPO)

Medical premium, deductible and limits

In-network and out-of-network

Monthly plan premium

Contact your group plan benefit administrator to

determine your actual premium amount, if applicable.

Annual medical deductible

Your plan has an annual combined in-network and

out-of-network medical deductible of $150 each plan

year.

Maximum out-of-pocket amount

(does not include prescription drugs)

Your plan has an annual

combined in-network and

out-of-network out-of-pocket maximum of $2,400 for

this plan year.

If you reach the limit on out-of-pocket costs, you keep

getting covered for hospital and medical services and

we will pay the full cost for the rest of the plan year.

Please note that you will still need to pay your

monthly premiums, if applicable, and cost-sharing for

your Part D prescription drugs.

Medical benefits

In-network and out-of-network

Inpatient hospital care

$230 copay per day: for days 1-7

$0 copay per day: for days 8 and beyond

Our plan covers an unlimited number of days for an

inpatient hospital stay.

Outpatient

hospital

Ambulatory

surgical center

(ASC)

20% coinsurance

UnitedHealthcare 2026 Plan Guide — page 8

Medical benefits

In-network and out-of-network

Cost sharing for

additional plan

covered services

will apply.

Outpatient

surgery

20% coinsurance

Outpatient

hospital services,

including

observation

20% coinsurance

Doctor

visits

Primary care

provider (PCP)

$20 copay

Virtual visit

$0 copay for designated providers

$20 copay for other providers

Specialist

$40 copay

Preventive

services

Routine physical

$0 copay; 1 per plan year*

Medicare-covered

$0 copay

Abdominal aortic aneurysm

screening

Alcohol misuse counseling

Annual wellness visit

Bone mass measurement

Breast cancer screening

(mammogram)

Cardiovascular disease

(behavioral therapy)

Cardiovascular screening

Cervical and vaginal cancer

screening

Colorectal cancer screenings

(colonoscopy, fecal occult blood

test, flexible sigmoidoscopy)

Depression screening

Diabetes screenings and

monitoring

Diabetes – Self-Management

training

Dialysis training

Glaucoma screening

Hepatitis C screening

HIV screening

Kidney disease education

Lung cancer with low dose

computed tomography (LDCT)

screening

Medical nutrition therapy

services

Medicare Diabetes Prevention

Program (MDPP)

Obesity screenings and

counseling

Prostate cancer screenings

(PSA)

Sexually transmitted infections

screenings and counseling

Tobacco use cessation

counseling (counseling for

people with no sign of tobacco-

related disease)

UnitedHealthcare 2026 Plan Guide — page 9

Medical benefits

In-network and out-of-network

Vaccines, including those for the

flu, Hepatitis B, pneumonia, or

COVID-19

“Welcome to Medicare”

preventive visit (one-time)

Any additional preventive services approved by Medicare during the

contract year will be covered.

This plan covers preventive care screenings and annual physical exams at

100%.

Emergency care

$90 copay (worldwide)

If you are admitted to the hospital within 24 hours,

you pay the inpatient hospital cost sharing instead of

the emergency care copay. See the “Inpatient

Hospital Care” section of this booklet for other costs.

Urgently needed services

$65 copay (worldwide)

If you are admitted to the hospital within 24 hours,

you pay the inpatient hospital cost sharing instead of

the urgently needed services copay. See the

“Inpatient Hospital Care” section of this booklet for

other costs.

Diagnostic tests,

lab and radiology

services, and X-

rays

Diagnostic

radiology services

(e.g. MRI, CT

scan)

20% coinsurance

Lab services

$0 copay

Diagnostic tests

and procedures

20% coinsurance

Therapeutic

radiology

20% coinsurance

Outpatient X-rays

20% coinsurance

Hearing services

Exam to diagnose

and treat hearing

and balance

issues

$40 copay

Routine hearing

exam

$0 copay, 1 exam per plan year*

UnitedHealthcare 2026 Plan Guide — page 10

Medical benefits

In-network and out-of-network

Hearing Aids

UnitedHealthcare

Hearing

Through UnitedHealthcare Hearing, the plan pays a

$500 allowance for

hearing aids (combined for both

ears) every 3 years. Hearing aid coverage under this

plan is only available through UnitedHealthcare

Hearing.

Vision

services

Exam to diagnose

and treat diseases

and conditions of

the eye

$40 copay

Eyewear after

cataract surgery

$0 copay

Routine eye exam

$0 copay, 1 exam every 12 months*

Mental

health

Inpatient visit

$230 copay per day: days 1-6

$0 copay per day: days 7-190

Our plan covers 190 days for an inpatient hospital

stay.

Outpatient group

therapy visit

$20 copay

Outpatient

individual therapy

visit

$40 copay

Outpatient

therapy or office

visit with a

psychiatrist

$40 copay

Virtual behavioral

visits

$40 copay

Skilled nursing facility (SNF)

$0 copay per day: days 1-20

$100 copay per day: days 21-44

$0 copay per day: days 45 and beyond

Our plan covers unlimited days in a SNF per benefit

period.

Outpatient Rehabilitation (physical,

occupational, or speech/language

therapy)

20% coinsurance

UnitedHealthcare 2026 Plan Guide — page 11

Medical benefits

In-network and out-of-network

Ambulance

$175 copay

Routine transportation

Not covered

Medicare Part B

Drugs

Part B drugs may

be subject to Step

Therapy. See your

Evidence of

Coverage for

details.

Chemotherapy

drugs

$0 copay

Other Part B

drugs

20% coinsurance

Prescription drugs

Deductible

$615

You pay the full cost for your drugs until you reach

the deductible amount. Then you move to the Initial

Coverage stage.

Initial coverage

In this stage, you’ll pay your plan copays or

coinsurance. The plan pays the rest. Once you, and

others on your behalf, have paid a combined total of

$2,100, which includes the amount you paid towards

your deductible, you move to the Catastrophic

Coverage stage.

Tier drug coverage

(After you pay your deductible,

applicable)

Retail Cost-Sharing

Mail Order

Cost-Sharing

30-day supply

90-day supply

Tier 1:

Preferred Generic

10% coinsurance, with a

$16 copay maximum

10% coinsurance, with a

$32 copay maximum

Tier 2:

Preferred Brand

20% coinsurance, with a

$85 copay maximum

20% coinsurance, with a

$170 copay maximum

Tier 3:

Non-Preferred Drug

40% coinsurance, with a

$170 copay maximum

40% coinsurance, with a

$345 copay maximum

Tier 4:

Specialty Tier

33% coinsurance, with a

$170 copay maximum

33% coinsurance, with a

$345 copay maximum

UnitedHealthcare 2026 Plan Guide — page 12

Prescription drugs

Catastrophic coverage

Once you’re in this stage, you won’t pay anything for

your Medicare-covered Part D drugs for the rest of the

plan year.

If your plan includes additional prescription drug

coverage, you will continue to pay the cost-sharing

amounts from the Initial Coverage stage for those

drugs. Please see your Additional Drug Coverage list

for more information.

Subject to Medicare guidance, coinsurance may not apply to Part D insulin products. You will pay a maximum of $35

for a 1-month supply of each Part D insulin product covered by our plan even if you haven’t paid your Part D

deductible. Most adult Part D vaccines are covered at no cost to you.

If the actual cost for a drug is less than the normal cost-sharing amount for that drug, you will pay

the actual cost, not the higher cost-sharing amount.

Your plan sponsor offers drug coverage in addition to your Part D prescription drug benefit. The

drug copays in this section are for drugs that are covered by both your Part D benefit and your

additional drug coverage. For more information, see your Additional Drug Coverage list. You can

also view the Certificate of Coverage at

retiree.uhc.com/EatonMAPD

or call Customer Service to

have a hard copy sent to you.

If you reside in a long-term care facility, you will pay the same for a 31-day supply as a 30-day

supply at a retail pharmacy.

You may qualify for Extra Help from Medicare

Extra Help is a program for people with limited incomes who need help paying Part D

premiums, deductibles and copays. There’s no penalty for applying, and you can re-

apply every year. To see if you qualify for Extra Help, call:

The Social Security Administration at 1-800-772-1213, TTY 1-800-325-0778

Your state Medicaid office

The UnitedHealthcare Savings Promise

UnitedHealthcare is committed to keeping your prescription drug costs down. As a

UnitedHealthcare member, you have our Savings Promise that you’ll get the lowest price

available. That low price may be your plan copay, the pharmacy’s retail price or our

contracted price with the pharmacy.

UnitedHealthcare 2026 Plan Guide — page 13

Additional benefits

In-network and out-of-network

Acupuncture

services

Medicare-covered

acupuncture

(for chronic low

back pain)

$20 copay

Routine

acupuncture

services

$20 copay, up to 12 visits per plan year*

Chiropractic

services

Medicare-covered

chiropractic care

(manual

manipulation of

the spine to

correct

subluxation)

$20 copay

Routine

chiropractic

services

$20 copay, up to 12 visits per plan year*

Diabetes

manage-

ment

Diabetes

monitoring

supplies

$0 copay

We only cover Contour® and Accu-Chek® brands.

Other brands are not covered by your plan.

Covered glucose monitors include: Contour Plus

Blue, Contour Next EZ, Contour Next Gen, Contour

Next One, Accu-Chek Guide Me and Accu-Chek

Guide.

Test strips: Contour, Contour Plus, Contour Next,

Accu-Chek Guide and Accu-Chek Aviva Plus.

Medicare covered

Continuous

Glucose Monitors

(CGMs) and

supplies

$0 copay

Diabetes self-

management

training

$0 copay

Therapeutic

shoes or inserts

20% coinsurance

UnitedHealthcare 2026 Plan Guide — page 14

Additional benefits

In-network and out-of-network

Durable medical

equipment (DME)

and related

supplies

Durable Medical

Equipment (e.g.,

wheelchairs,

oxygen)

20% coinsurance

Prosthetics (e.g.,

braces, artificial

limbs)

20% coinsurance

Wigs

$0 copay

The plan pays up to $500 per plan year for wigs for

hair loss due to chemotherapy*

Fitness program

Renew Active by

UnitedHealthcare

$0 copay for Renew Active by UnitedHealthcare, a

Medicare fitness program. It includes a gym

membership at a fitness location you select from our

national network, plus online classes and fun

activities outside of the gym, at no additional cost.

and select Access gym code or call the number on

your UnitedHealthcare member ID card to obtain your

code.

Foot care

(podiatry

services)

Foot exams and

treatment

$40 copay

Routine foot care

$40 copay, 6 visits per plan year*

UnitedHealthcare

Healthy at

Home

Post-discharge program

$0 copay for the following benefits for up to 30 days

following each inpatient hospital and SNF stay:

28 home-delivered meals, referral required

12 one-way trips to medically related

appointments and the pharmacy, up to 50 miles

per trip, referral required

6 hours of non-medical personal care services

like companionship, meal prep, medication

reminders and more with a professional

caregiver, no referral required

Services must be provided by approved vendors. Call

Customer Service for more information, to request a

referral after each discharge and to use your benefits.

UnitedHealthcare 2026 Plan Guide — page 15

Additional benefits

In-network and out-of-network

Home health care

$0 copay

Hospice

You pay nothing for hospice care from any Medicare-

approved hospice. You may have to pay part of the

costs for drugs and respite care. Hospice is covered

by Original Medicare, outside of our plan.

Opioid treatment program services

$0 copay

Outpatient

substance use

disorder services

Outpatient group

therapy visit

$20 copay

Outpatient

individual therapy

visit

$40 copay

Private duty nursing

We cover medically necessary skilled nursing

services provided in the home by a private duty nurse

who holds a valid, recognized nursing certificate and

is licensed according to state law in the state where

services are received. Services are covered when

provided through a Medicare-certified or

Accreditation Commission for Health Care (ACHC)

accredited provider that can provide services safely in

the home.

The services requested must be ordered by a treating

practitioner or specialist after a face-to-face evaluation

takes place with a written treatment plan and letter of

medical necessity. The face-to-face evaluation must

occur no more than 90 days prior to the service

request.

The services requested must require the professional

proficiency and skills of a registered nurse (RN),

licensed practical nurse (LPN) or licensed vocational

nurse (LVN) due to a complex medical need and/or

unstable condition. Caregiver or other appropriate

support must be available to assume a portion of

care.

Note: Custodial and domestic services are not

covered.

$0 copayment for each visit, up to $5,000 per plan

year

UnitedHealthcare 2026 Plan Guide — page 16

Additional benefits

In-network and out-of-network

Renal dialysis

20% coinsurance

Some of the network benefits listed may require your provider to obtain prior authorization. You never need approval

in advance for plan covered services from out-of-network providers. Please refer to the Evidence of Coverage for a

complete list of services that may require prior authorization.

Authorization is required for non-emergency Medicare-covered ambulance air transportation. Authorization is not

required for non-emergency Medicare-covered ambulance ground transportation. Emergency ambulance (ground or

air) does not require authorization.

*Benefits are combined in and out-of-network

UnitedHealthcare 2026 Plan Guide — page 17

About this plan

UnitedHealthcare® Group Medicare Advantage (PPO) is a Medicare Advantage

PPO plan with a

Medicare contract.

To join this plan, you must be entitled to Medicare Part A,

enrolled in Medicare Part B, live in our

service area as listed below, be a United States citizen or lawfully present in the United States, and

meet the eligibility requirements of your former employer, union group or trust administrator (plan

sponsor).

Our service area includes the 50 United States, the District of Columbia and all US territories.

About providers

and network pharmacies

UnitedHealthcare® Group Medicare Advantage (PPO) has a network of doctors, hospitals,

pharmacies

and other providers.

You can see any provider (network or out-of-network) at the same

cost share, as long as they accept the plan and have not opted out of or been excluded or

precluded from the Medicare program.

If you use pharmacies that are not in our network, the plan

may not pay for those drugs, or you may pay more than you pay at a network pharmacy.

You can go to

retiree.uhc.com/EatonMAPD

to search for a network provider

pharmacy using

the online

directories. You can also view the plan Drug List (Formulary) to see what drugs are

covered and if there are any restrictions.

UnitedHealthcare 2026 Plan Guide — page 18

Required Information

UnitedHealthcare® Group Medicare Advantage (PPO) is insured through UnitedHealthcare Insurance

Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract.

Enrollment in the plan depends on the plan’s contract renewal with Medicare.

Plans may offer supplemental benefits in addition to Part C and Part D benefits.

If you want to know more about the coverage and costs of Original Medicare, look in your current “Medicare

& You” handbook. View it online at medicare.gov or get a copy by calling 1-800-MEDICARE

(1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

UnitedHealthcare does not discriminate on the basis of race, color, national origin, sex, age, or disability in

health programs and activities.

UnitedHealthcare provides free services to help you communicate with us such as documents in other

languages, Braille, large print, audio, or you can ask for an interpreter. For more information, please call

Customer Service at the number on your member ID card or the front of your plan booklet.

UnitedHealthcare ofrece servicios gratuitos para ayudarle a que se comunique con nosotros. Por ejemplo,

documentos en otros idiomas, braille, en letra grande o en audio. O bien, usted puede pedir un intérprete.

Para obtener más información, llame a Servicio al Cliente al número que se encuentra en su tarjeta de ID de

miembro o en la portada de la guía de su plan.

This information is available for free in other languages. Please call our Customer Service number located

on the first page of this book.

Benefits, features and/or devices vary by plan/area.

Limitations and exclusions may apply.

Optum® Home Delivery Pharmacy and Optum Rx are affiliates of UnitedHealthcare Insurance Company. You

are not required to use Optum Home Delivery Pharmacy for medications you take regularly. If you have not

used Optum Home Delivery Pharmacy, you must approve the first prescription order sent directly from your

doctor to the pharmacy before it can be filled. Prescriptions from the pharmacy should arrive within 5

business days after we receive the complete order. There may be other pharmacies in our network. Optum

Home Delivery Pharmacy and Optum Rx affiliates are not available in all areas.

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice

when necessary.

You must continue to pay your Medicare Part B premium.

Out-of-network/non-contracted providers are under no obligation to treat UnitedHealthcare members,

except in emergency situations. Please call our customer service number or see your Evidence of Coverage

for more information, including the cost-sharing that applies to out-of-network services.

The Renew Active® Program and its gym network varies by plan/area and may not be available on all plans.

Participation in the Renew Active program is voluntary. Consult your doctor prior to beginning an exercise

program or making changes to your lifestyle or health care routine. Renew Active includes standard fitness

membership at participating locations and other offerings. The participating locations and offerings may

change at any time. Fitness membership equipment, classes and activities may vary by location. Certain

services, classes, activities and online fitness offerings are provided by affiliates of UnitedHealthcare

Insurance Company or other third parties not affiliated with UnitedHealthcare. Participation in these third-

party services is subject to your acceptance of their respective terms and policies. UnitedHealthcare is not

responsible for the services or information provided by third parties. The information provided through these

services is for informational purposes only and is not a substitute for the advice of a doctor.

Participation in the fitness program is voluntary. Consult your doctor prior to beginning an exercise program

or making changes to your lifestyle or health care routine. The fitness program includes standard fitness

membership and other offerings. Fitness membership equipment, classes, activities and events may vary by

location. Certain services, discounts, classes, activities, events and online fitness offerings are provided by

affiliates of UnitedHealthcare Insurance Company or other third parties not affiliated with UnitedHealthcare.

UnitedHealthcare 2026 Plan Guide — page 19

Participation in these third-party services is subject to your acceptance of their respective terms and

policies. UnitedHealthcare is not responsible for the services or information provided by third parties. The

information provided through these services is for informational purposes only and is not a substitute for the

advice of a doctor. Gym network may vary in local market and plan.

UHEX26NP0286696_000

UnitedHealthcare 2026 Plan Guide — page 20

Additional Drug Coverage

Your plan provides prescription drug coverage beyond what is listed in the

plan’s Drug List (Formulary).

To see the complete Drug List, scan the QR code or visit

Bonus drug list

Your plan includes coverage for the following prescription drugs that are not listed on your plan’s

Drug List. Each drug is placed into a tier. See the Summary of Benefits for tier descriptions and

costs.

Payments for these bonus drugs don’t count towards your Medicare Part D out-of-pocket

maximum.

You cannot file a Medicare appeal or grievance for these drugs and Extra Help from Medicare does

not apply to these drugs.

Drug name

Drug

tier

Coverage rules or limits on use

Analgesics - drugs to treat pain, inflammation, and muscle and joint conditions

Inflammation

Salsalate

Urinary Tract Pain

Phenazopyridine

Anorexiants - drugs to promote weight loss

Phentermine

QL (maximum of 1 capsule/tablet

per day)

Anticoagulants - drugs to prevent clotting

Heparin Lock Flush

Dermatological agents - drugs to treat skin conditions

Dry, Itchy Skin

Sulfacetamide Sodium (Liquid Wash 10%)

Sulfacetamide Sodium w/Sulfur (Cream

10-5%)

Itching Or Pain

Pramoxine/Hydrocortisone (Cream 1-2.5%)

Gastrointestinal agents - drugs to treat bowel, intestine and stomach conditions

Bold type = Brand name drug

Plain type = Generic drug

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UnitedHealthcare 2026 Plan Guide — page 21

Drug name

Drug

tier

Coverage rules or limits on use

Hemorrhoids

Hydrocortisone Acetate (Suppository 25 mg)

Lidocaine/Hydrocortisone (Perianal Cream

3%-0.5%)

Irritable Bowel Or Ulcers

Hyoscyamine Sulfate

Levbid

Genitourinary agents - drugs to treat bladder, genital and kidney conditions

Erectile Dysfunction

Edex

QL (maximum of 6 cartridges per

month)

Avanafil

QL (maximum of 6 tablets per

month)

Sildenafil (25 mg, 50 mg, 100 mg)

QL (maximum of 6 tablets per

month)

Tadalafil

QL (maximum of 6 tablets per

month)

Vardenafil

QL (maximum of 6 tablets per

month)

Sexual Desire Disorder

Addyi

QL (maximum of 1 tablet per day)

Vyleesi

QL (maximum of 8 injections per 30

days)

Urinary Tract Infection

Uro-MP (118 mg)

Urinary Tract Spasm And Pain

Belladonna Alkaloids & Opium (Suppositories)

MME, 7D, DL

Hormonal agents - hormone replacement/modifying drugs

Thyroid Supplement

Armour Thyroid

NP Thyroid

Nutritional supplements - drugs to treat vitamin and mineral deficiencies

Potassium Supplement

K-Phos (Tab)

Bold type = Brand name drug

Plain type = Generic drug

UnitedHealthcare 2026 Plan Guide — page 22

Drug name

Drug

tier

Coverage rules or limits on use

Potassium Bicarbonate (Effervescent Tab 25

mEq)

Vitamins And Minerals

Cyanocobalamin (Injection) (Vitamin B12)

(1000 mcg)

Folic Acid (1 mg) (Rx only)

Folic Acid-Vitamin B6-Vitamin B12 (Tablet

2.5-25-1 mg)

Phytonadione (Tab)

Reno (Cap)

Vitamin D (50,000 unit) (Rx only)

Respiratory tract agents - drugs to treat allergies, cough, cold and lung conditions

Cough And Cold

Benzonatate (100 mg, 200 mg)

Brompheniramine/Pseudoephedrine/

Dextromethorphan (Syrup)

Guaifenesin/Codeine (Syrup)

Hydrocodone Polst/Chlorpheniramine (ER

Susp) (generic for Tussionex)

Hydrocodone/Homatropine

Promethazine/Codeine (Syrup)

Promethazine/Dextromethorphan (Syrup)

Bold type = Brand name drug

Plain type = Generic drug

Drugs with coverage rules or limits are noted in the chart and described below.

QL - Quantity limits

The plan will only cover a certain amount of this drug for one copay or over a certain number of

days. These limits can help ensure safe and effective use of the drug.

MME - Morphine Milligram Equivalent

Additional quantity limits may apply to all opioid drugs used to treat pain. This additional limit is

called a cumulative Morphine Milligram Equivalent (MME). It’s designed to monitor safe dosing

levels of opioids for people who may be taking more than one opioid drug for pain management. If

your doctor or prescriber prescribes more than this amount or thinks the limit is not right for your

situation, you or your doctor or prescriber can ask the plan to cover the additional quantity.

UnitedHealthcare 2026 Plan Guide — page 23

7D - 7-day limit

An opioid drug used to treat pain may be limited to a 7-day

supply if you don’t have a recent history

of using opioids. This limit helps minimize long-term opioid use. If you are new to the plan and have

a recent history of using opioids, the pharmacy may override the limit when appropriate.

DL - Dispensing limit

Dispensing limits apply to this drug. This drug is limited to a one-month supply per prescription.

BDL: U

This information is not a complete description of benefits. Contact the plan for more information.

Limitations, copay, and restrictions may apply.

Benefits and/or copay/coinsurance may change each plan/benefit year.

The Drug List may change at any time. You will receive notice when necessary.

This information is available for free in other languages. Please call our Customer Service number on the

cover.

Y0066_070524_011500_C

CGEX26MP0314352_000

UnitedHealthcare 2026 Plan Guide — page 24

Here’s what you can expect next

Once you’re a member, the UnitedHealthcare Customer Service team and your online account

make it easier to get the care you need, when and how you need it.

You are here

UnitedHealthcare will

process your enrollment

Create your

account to review

your plan online

Receive

your member ID

card in the mail

Coverage begins!

Start using

your plan

Manage your plan online

If you haven’t done so already, use your Medicare number or member ID number and email

address to create an account at

retiree.uhc.com/EatonMAPD

. Online you can:

•

Look up your latest claim information and complete your health assessment

•

Find network providers, pharmacies, your Drug List (Formulary) and other benefit information

and plan materials

•

Learn more about health and wellness topics

•

Once your coverage begins

•

Schedule your annual wellness visit

•

Get a yearly in-home visit with Optum® HouseCalls. Visit

UHCHouseCalls.com

to learn more

•

Get your medications with free delivery through Optum® Home Delivery Pharmacy*

Benefits and costs may change at the end of your plan year

We’ll send you an Annual Notice of Changes before your plan year ends that will tell you about any

changes to your plan for the next plan year.

Thank you for trusting UnitedHealthcare with

your health care coverage

If you have any questions, please call the toll-free number

on the back of this Plan Guide. This number will also be

on your member ID card when you get it.

Scan this code

to access the

member

site

*Optum® Home Delivery Pharmacy and Optum Rx affiliates are not available in all areas.

Y0066_GRP_HWYCEN_2026_C

UHEX26NP0286693_000

UnitedHealthcare 2026 Plan Guide — page 25

Statements of understanding

By enrolling in this plan, I agree to the following:

This is a Medicare Advantage Plan contracted with the federal government. This is not a

Medicare Supplement Plan.

I need to keep my Medicare Part A and

Part B, and continue to pay my Medicare Part B and, if

applicable, Part A premiums, if they are not paid for by Medicaid or a third party. To be eligible

for this plan, I must live in the plan’s service area and be a United States citizen or be lawfully

present in the U.S.

The service area includes the 50 United States, the District of Columbia and all U.S.

territories.

I may not be covered while out of the country, except for limited coverage near the U.S. border.

However, under

this plan, when I am outside of the U.S. I am covered for emergency or

urgently needed care

I can only have one Medicare Advantage or Prescription Drug Plan at a time.

• Enrolling in this plan will automatically disenroll me from any other Medicare health plan.

• If I enroll in a different Medicare Advantage Plan

or Medicare Part D Prescription Drug Plan,

I will be automatically

disenrolled from this plan.

• If I disenroll from this plan, I will be automatically transferred to Original Medicare.

• Enrollment in this plan is for the entire plan year. I may leave this plan

only at certain times

of the year or under special conditions.

My information will be released to Medicare and other plans, only as necessary, for

treatment, payment and health care operations.

Medicare may also release my information for research and other purposes that follow all

applicable federal statutes and regulations.

For members of the Group Medicare Advantage Plan.

I understand that when my coverage begins, I must get all of my medical and prescription drug

benefits from the plan. Benefits and services provided by the plan and contained in the

Evidence of Coverage (EOC) document will be covered. Neither Medicare nor the plan will pay

for benefits or services that are not covered.

Y0066_SOU_2026_C

UHEX26NP0309711_000

UnitedHealthcare 2026 Plan Guide — page 26

Notice of nondiscrimination

Our Companies comply with applicable civil rights laws and do not discriminate on the basis

of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation,

and gender identity). We do not exclude people or treat them less favorably because of

race, color, national origin, age, disability, or sex.

We provide free aids and services to help you

communicate with us. You can ask for interpreters and/or

for communications in other languages or formats such

as large print. We also provide reasonable modifications

for persons with disabilities.

If you need these services, call the toll-free number on your

member identification card (TTY

711

If you believe that we failed to provide these services or discriminated in another way

on the basis of race, color, national origin, age, disability, or sex, you can send a complaint

to the Civil Rights Coordinator:

Civil Rights Coordinator

UnitedHealthcare Civil Rights Grievance

P.O. Box 30608

Salt Lake City, UT 84130

UHC_Civil_Rights@uhc.com

Optum Civil Rights Coordinator

1 Optum Circle

Eden Prairie, MN 55344

Optum_Civil_Rights@Optum.com

If you need help filing a complaint, call the toll-free number on your member identification

card (TTY

711

You can also file a civil rights complaint with the U.S. Department of Health and Human

Services, Office for Civil Rights:

Online:

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Phone:

1-800-368-1019, 800-537-7697

(TDD)

Mail:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

Complaint forms are available at:

http://www.hhs.gov/ocr/office/file/index.html

This notice is available at:

https://www.uhc.com/nondiscrimination-med

https://www.optum.com/en/language-assistance-nondiscrimination.html

UHEX26MP0358170_000

UnitedHealthcare 2026 Plan Guide — page 27

Notice of availability

of language assistance services and alternate formats

ATTENTION: Free language assistance services and free communications in other

formats, such as large print, are available to you. Call the toll-free number on your

member identification card.

ማሳሰቢያ፦ አማርኛ

(Amharic)

የሚናገሩ ከሆነ፣ ነፃ የቋንቋ እገዛ አገልግሎቶች እና ነፃ ተግባቦቶች እንደ ትልቅ እትም

ባሉ ሌሎች ቅርፀቶች ለእርስዎ ይገኛሉ። በአባልነት መታወቂያ ካርድዎ ላይ ያለውን ነፃ የስልክ ቁጥር ይደውሉ።

ملاحظ ة

:إ ذ ا

كن ت

ت ت حدث

اللغ ة

الغرب ي ة

(Arabic)

، ست ت وف ر

لك

خ دماث

المساعدة

اللغ وت ة

المح ان ت ة

والمراسلاث

المح ان ت ة

ن ت ن ست ق اث

،إ

خ رى مت ل

الطن اعة

ن أ

خرف

كن ت ر ة .ا ت صل

ن الرف م

المح ان ي

المدون علي

ن طاف ة

ت غرت ف الغص و

خ اصت ك.

দেখুন

: আপনি যনি

বা

èলায়

(Bengali)

কথা বলেি, তাহলে নবিামূলেে ভাষা সহা

ħতা পনিলষবা এবং বĥ মুƹলেি মলতা অিোিে

ফিমোলে যযাগালযাগ

ʦনে আপিাি জিে নবিামূলেে উপেɎ

। আপিাি সিলসেি পনিচ

ħপলেি কালডেি যোে

-নি ি

˟লি কে কˠি

請

注意

：

如果您

說

中文

(Chinese)

，您可以獲得免費語言協助服務和大字

體

等其他格式的

免費通訊。

請

致電您的會員身份卡上的免付費電話號碼。

ت وج ه

: اگ ر ب ه ز ب ان

ارسی

(Farsi)

صحب ت می گب ی د، خ دمات زای گ ان گمک ز ب اب ی و ازی ب اطات زای گ ان دز

ق الت های دی گ ر، ماب ب د خ ات ب ر زگ ، دز دسی رس س ما هسی ب د. ب ا س مازه زای گ ان مب دزج زوی گازت

س ب اسای ی عض وی ت

ی ان ی ماس ب گ ی ری د.

ATTENTION : Si vous parlez français (French), des services d’assistance linguistique

et des communications dans d’autres formats, notamment en gros caractères, sont

mis à votre disposition gratuitement. Appelez le numéro gratuit figurant sur votre

carte de membre.

ATANSYON: Si w pale Kreyòl Ayisyen (Haitian Creole), gen sèvis lang gratis ak

kominikasyon nan lòt fòma lo disponib, tankou sa ki enprime ak gwo lèt. Rele

nimewo gratis ki sou kat idantifikasyon manm ou an.

ATENSION: No agsasaoka iti Ilocano (Ilocano), magun-odmo dagiti libre a serbisio

ti tulong iti pagsasao ken libre a komunikasion iti dadduma a pormat, kas iti

dadakkel a letra. Tawagan ti awan-bayadna a numero a masarakan iti kard a

pakabigbigam kas miembro.

UnitedHealthcare 2026 Plan Guide — page 28

注意事項

：

日本語

(Japanese)

を話される場合、無料の言語支援サービスや、拡大文字

など他の形式での無料のコミュニケーションをご利用いただけます。会員証に記載され

ているフリーダイアルにお電話ください。

알림

사

항

한국어

(Korean)

를

사

용하시는

경우

무료

언

어

지원

서비스와

대형

활자체

등

다른

형식으로

된

의사

소통

매체를

이용하실

수

있습니다

회원

카드에

나와

있는

무료

전화번호로

전화해

주

십시오

UWAGA

: Dla osób mówiących po

polsku

(Polish)

dostępne są bezpłatne usługi

pomocy językowej i bezpłatne komunikaty w innych formatach, takich jak duży

druk. Prosimy zadzwonić pod bezpłatny numer podany na karcie identyfikacyjnej.

ATENÇÃO: se você fala português (Portuguese), tem à sua disposição serviços

gratuitos de assistência linguística e comunicações gratuitas em outros formatos,

como caracteres grandes. Ligue para o número gratuito que se encontra no seu

cartão de identificação de membro.

ВНИМАНИЕ

! Если вы говорите на

русском

языке

(Russian)

, вам доступны

бесплатные услуги языковой поддержки и бесплатные материалы в других

форматах, например напечатанные крупным шрифтом. Звоните по бесплатному

номеру телефона, указанному на вашей идентификационной карте участника.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas y

comunicaciones en otros formatos como letra grande, sin cargo, a su disposición.

Llame al número gratuito que figura en su tarjeta de identificación de miembro.

PAUNAWA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga

libreng serbisyo ng tulong sa wika at libreng komunikasyon sa ibang mga format,

tulad ng malalaking print. Tawagan ang walang bayad na numero na nasa iyong ID

card ng miyembro.

LƯU Ý

: Nếu quý vị nói

Tiếng

Việt

(Vietnamese)

, quý vị sẽ được cung cấp các dịch

vụ hỗ trợ ngôn ngữ miễn phí và các phương tiện trao đổi liên lạc miễn phí ở các

định dạng khác, chẳng hạn như bản in chữ lớn. Gọi đến số điện thoại miễn phí có

trên thẻ định danh thành viên của quý vị.

אויפמערק

: אויב איר רעדט

אידיש

(

Yiddish

(

, קענט איר באקומען אומזיסטע שפראך הילף

סערוויסעס און אומזיסטע קאמיוניקאציע אויף אנדערע פארמאטן, אזוי ווי גרויסע אותיות. רופט

דעם אומזיסטן נומער אויף אייער מעמבער אידענטיפיקאציע קארטל

UHEX26HM0279541

000

UnitedHealthcare 2026 Plan Guide — page 29

NOTES

_______________________________________________________________________________________

UnitedHealthcare 2026 Plan Guide — page 30

NOTES

_______________________________________________________________________________________

UnitedHealthcare 2026 Plan Guide — page 31

NOTES

_______________________________________________________________________________________

UnitedHealthcare 2026 Plan Guide — page 32

UHEX26NP0286688_001

Y0066_GRPCov_2026_C

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With exclusive benefits for retirees like you, get more of what matters for your health

with a group Medicare Advantage plan from UnitedHealthcare.

Let us help you. You’ve earned it.

Download the UnitedHealthcare app

Visit

retiree.uhc.com/EatonMAPD

and select the

Chat now

button

Call toll-free

1-866-859-0849,

TTY

711

8 a.m.-8 p.m. local time, Monday-Friday

Scan this code

to download the

UnitedHealthcare

app

Important Plan Information

UnitedHealthcare 2026 Plan Guide

Prompt to Clone This UnitedHealthcare 2026 Plan Guide

Apply this example's core structure, strategic pacing, and structural hierarchy directly to your own topic.

What are you generating today?