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, OR
- you are retired and have a dependent on Medicare, OR
- 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, Behavioral Health and Substance Abuse.
- Find a Provider
- Coverage Chart
- Pharmacy Benefits
- Behavioral Health and Substance Abuse Benefits
- Dental Plan
- Frequently Asked Questions
- Other Contacts
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.
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
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 | Plan pays 70% after deductible3 |
| 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 90% 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 |
- 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 and co-insurance.
- 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.
- All payments are based on the allowable charge. You are responsible for charges when receiving out-of-network services.
- 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 | |
| Generic (No deductible applies.) | First three purchases of any medication: $15 (or cost of drug if less) After third purchase of a long-term medication: 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.) | First three purchases of any medication: $50 After third purchase of a long-term medication: 50% (Min. $70, max. $165) |
|
| Non-Formulary (Annual $100 per person deductible applies at retail and participating on-site Duke pharmacies.) | First three purchases of any medication: $70 After third purchase of a long-term medication: 50% (Min. $85, max. $180) |
|
Behavioral Health and Substance Abuse Benefits
(Adminstered by UMR)
| In-Network or Medicare Accepting Provider | Out-of-Network or Non-Medicare Accepting Provider | |
|---|---|---|
| Outpatient |
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| Inpatient |
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- 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 | $2,000 per person | $1,250 per person | $1,000 per person |
| Preventive: All three plans cover: | |||
| No deductible Covered in full up to the MAC1. | No deductible Covered in full up to U&C2. | No deductible Pays a predetermined fixed amount3 based on procedure received. |
| Basic: All three plans cover: | |||
| No deductible; Reimbursement at:
| After $100 lifetime deductible per person; Reimbursement at:
| After a combined basic and major annual deductible of $50 per person, the plan pays a predetermined fixed amount3 based on procedure received. |
| Major: All three plans cover: | |||
| After a $50 calendar year deductible per person; Reimbursement at:
| After a $75 calendar year deductible per person; Reimbursement at:
| After a combined basic and major annual deductible of $50 per person, the plan pays a predetermined fixed amount3 based on procedure received. |
| Orthodontia: | |||
| All three plans cover orthodontia only if treatment begins after the participant becomes covered by a Duke Dental Plan. | No deductible. 50% of U&C2 $1,000 lifetime orthodontia maximum benefit per person (adults and children) | No deductible. 50% of U&C2 $1,000 lifetime orthodontia maximum benefit per person (adults and children) | No deductible. 50% of U&C2 $750 lifetime orthodontia maximum benefit per person (adults and children) |
- All payments are based on the Maximum Allowable Charges (MAC). PPO dentists have agreed to accept the contracted fee (MAC) as the maximum charge.
- All payments are based on the usual and customary (U&C) allowable charge. You are responsible for charges over U&C.
- The fee schedule, or reimbursement for each type of dental procedure, is available on the Ameritas website at ameritas.com.
Frequently Asked Questions
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.
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.
No. Duke Plus is an open-access plan, which means you do not need a referral to see a specialist.
No. The amount your Retiree Health Plan will pay is unlimited.
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.
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.
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.
If you or any of your covered family members are Medicare-eligible, the entire family will be enrolled in Duke Plus.
If you are a retiree, you will need to enroll in Medicare Part B.
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.
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.
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.
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.
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 residents, call Senior PharmAssist: 919-688-4772 |
For additional information about Medicare and Social Security, please see the Retirement Planning Guide.