You are here

Duke Plus

More Information

file type icon 2022 Duke Plus Summary
file type icon Duke Plus Member Guide

Contact Information

UMR - Duke Plus (Medical & Behavioral Health/Substance Abuse)
866-318-DUKE (3853)

Express Scripts - Medicare Prescription Plan (PDP)
800-877-8185

Ameritas - Dental
800-487-5553

Medicare
800-633-4227

Claim Form

Duke Plus is Duke's retiree health plan administered by UMR. You may continue your health insurance coverage on the Duke Plus plan if:

View the Duke Plus Summary Chart for an overview of what is covered by the plan including Pharmacy, Behavioral Health and Substance Abuse.

Find a Provider

If you or a covered dependent are Medicare-eligible, you may see any provider who accepts Medicare. For further assistance please call the number on the back of your Duke Plus Member card. If you or a covered dependent are not Medicare-eligible, please visit the United Health Choice Network website to locate an in-network provider.

Coverage Chart

  In-Network or Medicare Accepting Provider Out-of-Network or Non-Medicare Accepting Provider
Lifetime Maximum Plan Payment Unlimited Unlimited
Deductible
Individual None $650
Family None $1,950
Co-Insurance Maximum
Individual None $4,0002
Family None $12,0002
Physician Office Visit
PCP $20 co-pay Plan pays 70% after deductible3
Specialist $55 co-pay Plan pays 70% after deductible3
MRI, CT, PET Scan $150 co-pay Plan pays 70% after deductible3
Lab & Other X-Ray Covered in full Plan pays 70% after deductible3
Allergy Injections Covered in full Plan pays 70% after deductible3
Allergy Testing $55 co-pay per visit Plan pays 70% per visit after deductible3
Annual Physical $20 co-pay primary care
$55 co-pay specialist		 Well visits not covered;
Plan pays 70% after deductible3 for annual Pap smear, mammogram, and PSA
Mammogram Covered in full Plan pays 70% after deductible3
Colonoscopy and Cologuard® Colorectal Screening Covered in full Plan pays 70% after deductible3
OB/GYN Exams $20 co-pay primary care
$55 co-pay specialist		 Well visits not covered;
Plan pays 70% after deductible3 for annual Pap smear, mammogram, and sick visits
Routine Immunizations Covered in full Not Covered
Well Baby Visits (under age 2) Covered in full Not covered
Maternity Care: includes prenatal and post-delivery care $55 first visit,
then professional services covered in full		 Plan pays 70% after deductible3
Hospital Care
Inpatient $600 per admission at Duke Hospital, Duke Regional Hospital or Duke Raleigh Hospital; $700 per admission at other network hospitals Plan pays 70% after deductible and
$900 per admission co-pay3
Outpatient $250 co-pay Plan pays 70% after deductible3
Emergency Care $250 co-pay, waived if admitted $250 co-pay, waived if admitted
Urgent Care $35 co-pay $35 co-pay
Ambulance Covered in full when medically necessary Covered in full when medically necessary
Other Services
Infertility Not covered Not covered
Routine Infertility Testing and Treatment Not covered Not covered
Hearing Aids Not covered Not covered
Skilled Nursing Facility $250 per admission co-pay, then covered in full for 60 days1 when authorized by doctor $250 per admission co-pay, then covered in full for 60 days1 when authorized by doctor
Home Health Care Covered in full when authorized by doctor;
up to 100 visits per calendar year1		 Covered in full when authorized by doctor;
up to 100 visits per calendar year1
Hospice Care Covered in full when authorized by doctor Covered in full when authorized by doctor
Durable Medical Equipment You pay 10%; plan pays up to $15,000 annual limit1 Plan pays 70% after deductible4;
plan pays up to $15,000 annual limit1
Prosthetics You pay 10%; plan pays up to $15,000 annual limit1 Plan pays 70% after deductible4;
plan pays up to $15,000 annual limit1
Physical Therapy (PT)
Occupational Therapy (OT)		 $20 co-pay;
40 visits per calendar year for combined PT and OT1,5		 Plan pays 70% after deductible4;
40 visits per calendar year for combined PT and OT1,5
Chiropractic Care $55 co-pay;
plan pays up to $750 annual maximum1		 Plan pays 70% after deductible4;
$750 annual maximum1
Speech Therapy $20 co-pay; 20 visits per calendar year1;
precertification required5		 Plan pays 70% after deductible4;
20 visits per calendar year for combined in- and out-of-network1,5
Nutritionist $20 co-pay; 6 visits per calendar year Plan pays 70% after deductible4; 6 visits per calendar year
Vision Exam $55 co-pay; limit 1 per calendar year Not covered
  1. The benefits for in-network and out-of-network are combined.
  2. Excluding deductibles, co-pays, prescription drug co-pays, urgent care and emergency room co-pays, and mental health co-pays and co-insurance.
  3. All payments are based on the usual, customary, and reasonable (UCR) allowable charge. You are liable for charges over UCR when receiving out-of-network services.
  4. All payments are based on the allowable charge. You are responsible for charges when receiving out-of-network services.
  5. There are no benefits available under this plan for children with developmental disabilities.

Pharmacy Benefits

Listed below is the information about the Express Scripts Medicare Part D Prescription Plan (PDP) for Duke University.

Co-Pay Structure At a participating retail pharmacy Through the Express Scripts Mail Order Pharmacy or Participating On-Site Duke Pharmacies
Up to a 31-day supply 90-day supply
First three purchases of any medication After third purchase of a long-term medication Anytime
Generic
(No deductible applies.)		 $15
(or cost of drug if less)		 50%
(Cost of drug to max. $30)		 No deductible
$25
(or cost of drug if less)
Brand
(Annual $100 per person deductible applies at retail and participating on-site Duke pharmacies.)		 $50 50%
(Min. $70, max. $165)
  • Mail order - No deductible and $130 co-pay
  • On-Site Duke Pharmacies - $100 deductible and $130 co-pay
Non-Formulary
(Annual $100 per person deductible applies at retail and participating on-site Duke pharmacies.)		 $70 50%
(Min. $85, max. $180)
  • Mail order - No deductible and $180 co-pay
  • On-Site Duke Pharmacies - $100 deductible and $180 co-pay

Behavioral Health and Substance Abuse Benefits

(Adminstered by UMR)

  In-Network or Medicare Accepting Provider Out-of-Network or Non-Medicare Accepting Provider
Outpatient
  • $20 co-pay per visit for individual/family therapy
  • Precertification required for psychological testing, electroshock therapy, and hypnosis
  • After $650 annual deductible, plan pays 70% of allowable charge1
Inpatient
  • Co-pay of $600 per admission at Duke Hospital, Duke Regional Hospital or Duke Raleigh Hospital; $700 per admission at other network hospitals
  • Must be precertified prior to admission
  • After $900 per admission co-pay, plan pays 70% of allowable charge1
  • Must be precertified prior to admission
  1. All payments are based on the allowable charge. You are liable for charges over the allowable charge when receiving out-of-network services.

Dental Plan

  PPO Plan In-network Plan A Plan B
Annual Maximum Benefit for Preventive, Basic, and Major Covered Services $1,250 per person1 $1,000 per person1 $750 per person1
Preventive:
  • 2 routine exams per year
  • 2 routine prophylaxis (cleanings) per year
  • Space maintainers
  • X-rays
  • Fluoride treatments (for children under age 19)
 No deductible
Covered in full up to the MAC2		 No deductible
Covered in full up to U&C3		 No deductible
Pays a predetermined fixed amount4 based on procedure received
Basic:
  • Fillings
  • Sealants
  • Full or partial denture repair
  • Anesthesia for oral surgery
  • Removal of teeth
 No deductible
Reimbursement at:
  • 80% of MAC2 during first year of coverage
  • 90% of MAC2during second year of coverage if a covered procedure is received during the first year
  • 100% of MAC2thereafter if a covered procedure is received in second and following years
 After $100 lifetime deductible per person, reimbursement is:
  • 80% of U&C3 during first year of coverage
  • 90% of U&C3 during second year of coverage if a covered procedure is received during the first year
  • 100% of U&C3 thereafter if a covered procedure is received in second and following years
 After a combined basic and major annual deductible of $50 per person, the plan pays a predetermined fixed amount4 based on the procedure received
Major:
  • Crowns
  • Bridgework
  • Partial or full dentures
  • Dentures, prosthodontics, and inlays
  • Periodontal maintenance (periodontal cleaning) and gum treatment
  • Endodontic procedures (root canals, etc.)
 After $50 calendar year deductible per person, reimbursement is:
  • 50% of MAC2
  • 65% of MAC2for periodontal or gum treatment
  • 65% of MAC2for endodontic procedures
 After $75 calendar year deductible per person, reimbursement is:
  • 50% of U&C3
  • 65% of U&C3for periodontal or gum treatment
  • 65% of U&C3for endodontic procedures
 After a combined basic and major annual deductible of $50 per person, the plan pays a predetermined fixed amount4 based on the procedure received
Orthodontia:
Benefits payable only if treatment begins after the participant becomes covered by a Duke Dental Plan		 No deductible
50% of U&C3;
$1,000 lifetime orthodontia maximum benefit per person (adults and children)		 No deductible
50% of U&C3;
$1,000 lifetime orthodontia maximum benefit per person (adults and children)		 No deductible
50% of U&C3;
$750 lifetime orthodontia maximum benefit per person (adults and children)
  1. Dental Plan members who visited the dentist and had at least one dental claim filed in calendar year 2020, with less than $500 in claims payments, will have their annual maximum benefit increased by $250 in 2021. This accumulation can continue until the annual maximum has increased on the PPO from $1,250 to $2,250; on Plan A from $1,000 to $2,000; on Plan B, from $750 to $1,750.
  2. All payments are based on the Maximum Allowable Charges (MAC). PPO dentists have agreed to accept the contracted fee (MAC) as the maximum charge.
  3. All payments are based on the usual and customary (U&C) allowable charge. You are liable for charges over U&C.
  4. The fee schedule, or reimbursement for each type of dental procedure, is available on the Ameritas website at ameritas.com.

Frequently Asked Questions

I am an early retiree and I/my spouse just became eligible for Medicare because of disability. Do we have to sign up for Medicare?

Yes, when you are not actively employed and become eligible for Medicare due to age or disability, you are required by our plans to enroll in Medicare Part A and Part B and contact our office.

How do I know if my provider is considered in-network?

If you or a family member is Medicare-eligible, then they will be able to receive benefits at the in-network level as long as your doctor accepts Medicare. Duke providers accept Medicare. If you see a doctor who does not accept Medicare, your claim will be paid as out-of-network.

If you or a family member is NOT Medicare-eligible, they may use any provider in the nationwide network. Using an in-network provider will result in increased savings versus using a provider who is not in the network. The network is UHC Choice Plus. You may locate an in-network provider by calling toll-free, 1-866-318-3853 or by logging on to the UMR website.

Do I need a referral to see a specialist?

No. Duke Plus is an open-access plan, which means you do not need a referral to see a specialist.

Is there a Lifetime Maximum Benefit Amount that my Retiree Health plan will pay?

No. The amount your Retiree Health Plan will pay is unlimited.

If I am age 65 or older and have Duke Plus, must I use mail order or On-Site Duke Pharmacies in order to fill a 90-day supply of a prescription?

No. If you are age 65 or older and have coverage through Duke Plus, you may receive a 90-day prescription supply of Generic or Brand drugs at any retail pharmacy, but will be charged three co-pays.

I am currently retired, can I add a dependent to my health plan as a result of a Qualifying Event?

Only those family members currently covered will be eligible for continued coverage. However, if you have a marriage that occurs on or after January 1, 2020, you will have a one-time opportunity to add your spouse to coverage within 30 days of the marriage date.

What happens if I decide to drop my coverage at a later date?

You can drop coverage at any time. However, if you drop coverage for any other reason than having coverage under an employer sponsored plan where you are the employee, you will not be able to re-enter the plan at a later date.

What do I do if my spouse is Medicare-eligible?

If you or any of your covered family members are Medicare-eligible, the entire family will be enrolled in Duke Plus.

Do I need to enroll in Medicare Part B when I reach age 65?

If you are a retiree, you will need to enroll in Medicare Part B.

How does Medicare affect my Duke health coverage?

If you are a retiree and eligible for Medicare, Duke pays secondary to Medicare. You will need to enroll in Medicare Part A and B and be enrolled in Duke Plus.

If I am Medicare-eligible and my doctor does not accept Medicare, will I have to complete claims forms?

Yes. You will be responsible for paying doctor charges upfront and filing a claim form with UMR. You will receive an out-of-network reimbursement. If you need assistance completing your claim forms, you may call UMR at 1-866-318-3853.

If I am retired, may I enroll in a plan that I do not currently have?

No, if you are not currently enrolled in a Duke health or dental plan, you cannot add this coverage. Also, you are not eligible to participate in the Reimbursement Accounts.

I can't afford my medical coverage right now, can I drop it and add it back at a later time?

No. If you drop coverage without going on another employer sponsored plan where you are the employee, you will permanently lose eligibility for the retiree plans.

I am a retiree and I just got a job through another employer and will have coverage through them. Can I drop my Duke coverage?

Yes. If you drop coverage due to gaining coverage through another employer sponsored plan where you are the employee, you may suspend your Duke coverage, however, you must provide proof of other coverage in order to maintain your eligibility to come back to the Duke plans within 60 days of the other coverage terminating.

Other Contacts

Social Security Administration ssa.gov
You can enroll in Medicare and request a duplicate Medicare ID card.		 Local Office: 1-888-759-3908
Regional Office: 800-772-1213
Medicare Part A, Hospital medicare.gov 800-633-4227
Medicare Part B, Medical medicare.gov 800-772-1213
UMR umr.com
Mail Claims to: UMR
P.O. Box 30541
Salt Lake City, UT 84130-0541
EDI Payer #39026		 Medical Claims and Precertifications: 1-866-318-DUKE (3853)
SHIIP (Seniors' Health Insurance Information Program) ncdoi.com/SHIIP NCSHIIP: 855-408-1212 option 1
Durham Council for Senior Citizens: 688-8247
Durham Cooperative Extension Service: 560-0521

For additional information about Medicare and Social Security, please see the Retirement Planning Guide.

Benefits