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Phelps Health Medicare Advantage (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Phelps Health Medicare Advantage (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Phelps Health Medicare Advantage (HMO) in 2026, please refer to our full plan details page.
Phelps Health Medicare Advantage (HMO) is a HMO plan offered by CoxHealth available for enrollment in 2026 to people living in Counties: CRA DEN MAR PHE PUL. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Phelps Health Medicare Advantage (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Phelps Health Medicare Advantage (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Phelps Health Medicare Advantage (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $400.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4200.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
Sign up for Phelps Health Medicare Advantage (HMO)
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Drug Coverage
The Phelps Health Medicare Advantage (HMO) plan features a $400 annual drug deductible and offers excellent savings on everyday medications. You will pay no copay for Tier 1 preferred generic drugs at preferred pharmacies or for Tier 6 select diabetic drugs at both preferred and standard pharmacies. Tier 2 generic drugs are also highly affordable, with copays starting at $10 for a one-month supply at preferred pharmacies. For brand-name and specialty medications, Tier 3 preferred brands require a $47 copay and Tier 4 non-preferred drugs require a $100 copay for a one-month supply at standard and preferred pharmacies. Specialty drugs in Tier 5 carry a 28% coinsurance for a one-month supply. Additionally, you can save on multi-month prescriptions with standard mail-order options, including no copay for a three-month supply of Tier 1 and Tier 6 medications.
Additional Benefits
The Phelps Health Medicare Advantage (HMO) plan offers affordable coverage for core medical needs, including primary care doctor visits and telehealth services with no copay and no coinsurance. For more specialized care, specialist visits require a $55 copay, while emergency room visits carry a $125 copay that is waived if you are admitted. Inpatient hospital stays require a $350 daily copay for the first six days and no copay thereafter, while outpatient hospital services require a $395 copay, both with no coinsurance. This plan also features valuable supplemental benefits to help manage your everyday wellness, including preventive and comprehensive dental care with no copay or coinsurance up to a $3,000 annual limit. Additionally, you will pay no copay or coinsurance for routine eyewear up to $200 annually, prescription hearing aids up to $1,150 per ear every two years, and select over-the-counter items up to $20 every three months. For recovery and medical supplies, skilled nursing facility stays have no copay for the first 20 days, and durable medical equipment is covered with no copay and a 20% coinsurance.
Inpatient Hospital See details
Phelps Health Medicare Advantage (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $350 daily copay for days 1 through 6 and no copay for days 7 and beyond. Prior authorization is required and unlimited additional days are covered, though non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient services covered by the Phelps Health Medicare Advantage (HMO) include outpatient hospital, observation, and ambulatory surgical center services for a $395 copay and no coinsurance. Outpatient substance abuse sessions require a $35 copay and no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Phelps Health Medicare Advantage (HMO) with a $50.00 copay and no coinsurance.
Ambulance and Transportation Services See details
Phelps Health Medicare Advantage (HMO) covers ground and air ambulance services with a $250 copay and no coinsurance, requiring prior authorization. While some transportation services are covered, transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Emergency services are covered by Phelps Health Medicare Advantage (HMO) with a $125 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services are covered with a $50 copay and no coinsurance, and worldwide emergency and urgent care are covered with a $125 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Phelps Health Medicare Advantage (HMO) offers primary care physician visits and telehealth services with no copay and no coinsurance. Specialist visits require a $55 copay, therapy services cost $20, and mental health, psychiatric, and podiatry services have a $35 copay, all with no coinsurance. Chiropractic services are partially covered, featuring a $20 copay and no coinsurance for up to 26 routine visits per year, while other chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered by Phelps Health Medicare Advantage (HMO) with no copay and no coinsurance, although prior authorization is required for Medicare-covered zero-dollar services. While memory fitness, kidney disease education, glaucoma screenings, and diabetes training are covered, the plan does not cover annual physical exams, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, home-palliative care, in-home support, caregiver support, smoking cessation, enhanced disease management, telemonitoring, remote access, home safety modifications, and counseling.
Hearing Services See details
Phelps Health Medicare Advantage (HMO) covers annual routine hearing exams and fitting evaluations with a $20 copay and no coinsurance. Prescription hearing aids are partially covered with no copay and no coinsurance up to a maximum of $1,150 per ear every two years, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Phelps Health Medicare Advantage (HMO) covers vision services, offering one routine eye exam per year for a $35 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a combined maximum of $200 annually for contacts, lenses, frames, and upgrades, with no deductibles applied to these services.
Dental Services See details
Dental services are partially covered by Phelps Health Medicare Advantage (HMO), providing covered preventive and comprehensive care with no copay and no coinsurance up to a $3,000 annual maximum. However, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Phelps Health Medicare Advantage (HMO) with no copay, though prior authorization is required. Associated Medicare Part B drugs, such as chemotherapy, radiation, and insulin, require no coinsurance to 20% coinsurance, with insulin also carrying a $35 copay.
Dialysis Services See details
Dialysis Services are covered by Phelps Health Medicare Advantage (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Phelps Health Medicare Advantage (HMO) covers medical equipment with no copays, though prior authorization is required. Durable medical equipment, prosthetics, and medical supplies are subject to a 20% coinsurance, while diabetic therapeutic shoes and inserts have no coinsurance and diabetic supplies carry a 0% to 20% coinsurance.
Diagnostic and Radiological Services See details
Phelps Health Medicare Advantage (HMO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. There is no copay for lab services, diagnostic procedures, and outpatient X-rays, while diagnostic radiological services have a minimum copay of $150 and therapeutic radiological services have a minimum copay of $60.
Home Health Services See details
Home Health Services are covered by the Phelps Health Medicare Advantage (HMO) plan with a $20.00 copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Phelps Health Medicare Advantage (HMO) provides Cardiac Rehabilitation Services with no coinsurance; however, only some services are covered, and cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Phelps Health Medicare Advantage (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance and requires no prior three-day hospital stay. There is no copay for days 1 through 20, a $200 copay for days 21 through 100, and unlimited additional days are fully covered.
Other Services See details
Phelps Health Medicare Advantage (HMO) partially covers other services, offering over-the-counter (OTC) items with no copay and no coinsurance up to a maximum reimbursement of $20 every three months. Acupuncture, meal benefits, and other miscellaneous services are not covered under this benefit.
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