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Presbyterian UltraFlex (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Presbyterian UltraFlex (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Presbyterian UltraFlex (HMO-POS) in 2025, please refer to our full plan details page.
Presbyterian UltraFlex (HMO-POS) is a HMO-POS plan offered by Presbyterian Healthcare Services available for enrollment in 2025 to people living in BER CIB CUR DON LIN QUA RIO SDV SFE SOC TOR VAL. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Presbyterian UltraFlex (HMO-POS) 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 Presbyterian UltraFlex (HMO-POS).
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 Presbyterian UltraFlex (HMO-POS), 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $8950.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $8950.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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:
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Drug Coverage
The Presbyterian UltraFlex (HMO-POS) plan has an "Enhanced Alternative" drug benefit type. This plan has no deductible for prescription drugs. In the initial coverage phase, you will pay a copay or coinsurance for your prescriptions. For preferred generic drugs, you will pay a $10 copay, while standard generic drugs have a $45 copay. For preferred brand drugs, you will pay 50% coinsurance, and for non-preferred drugs, you will pay 33% coinsurance. Once your total drug costs reach $2000, you enter the next coverage phase.
Additional Benefits
The Presbyterian UltraFlex (HMO-POS) plan offers a variety of benefits, including coverage for inpatient and outpatient hospital services, as well as emergency services, with varying copays. The plan also covers primary care, preventive services, hearing, vision, and dental services, with specific copays or coinsurance amounts for each. Additional benefits include home health services with no copay, and skilled nursing facility services with a copay after 20 days. The plan covers ambulance services, and offers other services such as acupuncture and an over-the-counter item allowance.
Inpatient Hospital See details
Inpatient Hospital coverage under the Presbyterian UltraFlex (HMO-POS) plan includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, both with a $450 copay for days 1-5, and no copay for days 6-90; additional days are covered with no copay. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a $350 copay, observation services with a $265 copay, and ambulatory surgical center services with a $350 copay. Outpatient substance abuse services are partially covered, but individual and group sessions for outpatient substance abuse are not covered, and outpatient blood services are covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Presbyterian UltraFlex (HMO-POS) plan, with a $45 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Presbyterian UltraFlex (HMO-POS) plan. Ground and Air Ambulance Services have a copay of $420, with no coinsurance, while Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Presbyterian UltraFlex (HMO-POS) plan. Emergency Services has a $125 copay, and Urgently Needed Services has a copay between $30 and $55. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation all have a $125 copay.
Primary Care See details
The Presbyterian UltraFlex (HMO-POS) plan covers primary care physician services, chiropractic services (with a $20 copay), occupational therapy services (with a $25 copay), physician specialist services (with a $45 copay), physical therapy and speech-language pathology services (with a $25 copay), and additional telehealth benefits. Mental health specialty services and psychiatric services are not covered.
Preventive Services See details
The Presbyterian UltraFlex (HMO-POS) plan covers a range of preventive services, including Medicare-covered services, annual physical exams, health education, medical nutrition therapy, additional sessions of smoking and tobacco cessation counseling, fitness benefits, enhanced disease management, telemonitoring services, remote access technologies, kidney disease education services, and other preventive services. However, in-home safety assessments, personal emergency response systems, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers of enrollees, and home and bathroom safety devices and modifications are not covered. Counseling services are covered with no copay.
Hearing Services See details
Hearing services include routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams are covered once per year, and fitting/evaluation for hearing aids are unlimited. Prescription hearing aids have a copay between $499 and $999, and are limited to 2 per year; however, inner ear, outer ear, and over the ear prescription hearing aids are not covered, and OTC hearing aids are also not covered.
Vision Services See details
Vision services are covered by the Presbyterian UltraFlex (HMO-POS) plan, including eye exams with a copay between $0 and $10, and eyewear with a 20% coinsurance. Eyewear benefits include a combined maximum of $90 every three months.
Dental Services See details
The Presbyterian UltraFlex (HMO-POS) plan covers Medicare Dental Services with a $55 copay. Other dental services like oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatments are covered, with each service limited to a certain number of visits per year. Orthodontic services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, and oral and maxillofacial surgery are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Presbyterian UltraFlex (HMO-POS) plan, including Medicare Part B Insulin Drugs with a $35 copay and between 0% and 20% coinsurance, as well as Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with between 0% and 20% coinsurance and a $10 copay for Other Medicare Part B Drugs. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Presbyterian UltraFlex (HMO-POS) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered by the Presbyterian UltraFlex (HMO-POS) plan. Durable Medical Equipment (DME) is covered with 20% coinsurance, and Prosthetic devices and Diabetic Therapeutic Shoes/Inserts are covered with a 20% coinsurance, while Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Presbyterian UltraFlex (HMO-POS) plan. Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $350.00. Therapeutic Radiological Services have a coinsurance of at most 20%, and Outpatient X-Ray Services have a $30.00 copay.
Home Health Services See details
Home Health Services are covered by the Presbyterian UltraFlex (HMO-POS) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Presbyterian UltraFlex (HMO-POS) plan. Specifically, Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Presbyterian UltraFlex (HMO-POS) plan, but require prior authorization. There is no copay for days 1-20, and a $210 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include acupuncture, over-the-counter (OTC) items, and a meal benefit. Acupuncture has a $25 copay, while OTC items are covered up to a $90 maximum every three months.
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