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(Duke Plus Members)
Duke Plus is Duke's retiree health plan administered by UMR. You may continue your health insurance coverage on the Duke Plus plan if you are eligible to continue health insurance as a retiree, and age 65 or over,
You are retired and have a dependent on Medicare,
You become disabled and are covered by Medicare.
View the Duke Plus Summary Chart for an overview of what is covered by the plan including Pharmacy, Mental 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.
|Social Security Administration||www.ssa.gov
You can enroll in Medicare and request a duplicate Medicare ID card.
|Local Office: 1-888-759-3908
Regional Office: 1-800-772-1213
|Medicare Part A, Hospital||www.medicare.gov||1-800-633-4227|
|Medicare Part B, Medical||www.medicare.gov||1-800-772-1213|
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)||www.ncdoi.com/SHIIP||NCSHIIP: 1-800-443-9354
Durham Council for Senior Citizens: 688-8247
Durham Cooperative Extension Service: 560-0521
For additional information about Medicare click here.
For additional information about Social Security click here.
or Medicare Provider
or Non-Medicare Provider
|Lifetime Maximum Plan Payment||$2 million1||$2 million1|
|Physician Office Visit|
|Primary Care Physician||$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 deductible2 for annual Pap smear, mammogram, and PSA|
|Mammogram||Covered in Full||Plan pays 70% after deductible3|
|Colonoscopy||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 deductible2 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||$55 first visit, then professional services covered in full||Plan pays 70% after deductible3|
|Inpatient||Per admission co-pay of $600 at Duke or $700 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|
|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; 20 visits per calendar year for combined PT and OT1,3||Plan pays 70% after deductible4; 20 visits per calendar year for combined PT and OT1,3|
|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 required3||Plan pays 70% after deductible4; 20 visits per calendar year for combined in- and out-of-network1,3|
|Nutrition||$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|
- The benefits for in-network and out-of-network are combined.
- Excluding deductibles, co-pays, prescription drug co-pays, urgent care and emergency room co-pays, and mental health co-pays.
- All payments are based on the allowable charge. You are liable for charges over the allowable charge.
- All payments are based on the allowable charge. You are liable for charges over the allowable charge when receiving out-of-network services.
Frequently Asked Questions
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. Most 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.
I am currently retired, can I add a dependent to my health plan, even if it is a Qualifying Event?
Only those family members currently covered will be eligible for continued coverage.
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, 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.
If I am Medicare-eligible and my doctor does not accept Medicare, will I have to complete claims forms?
Yes. You will need to complete claims forms if your provider does not accept Medicare and your claim will be processed as out-of-network. If you need assistance in completing your claims forms, you may call the Medicare Office at 1-800-772-1213
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 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.
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, 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, 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.