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PMC Max (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for PMC Max (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on PMC Max (HMO-POS) in 2025, please refer to our full plan details page.
PMC Max (HMO-POS) is a HMO-POS plan offered by Elevance Health, Inc. available for enrollment in 2025 to people living in Puerto Rico. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that PMC Max (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 PMC Max (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 PMC Max (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 $3250.00 (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 $3250.00 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 PMC Max (HMO-POS) plan offers an enhanced alternative drug benefit. There is no deductible for prescription drugs. During the initial coverage phase, you will pay different copays or coinsurance amounts depending on the drug tier and pharmacy. For example, you'll pay no copay for preferred generic drugs at a standard pharmacy, $7 for standard generic drugs, and $10 for preferred brand drugs. Non-preferred drugs have a 25% coinsurance, and specialty tier drugs have a 33% coinsurance. Once your total drug costs reach $2000, you will enter the next coverage phase.
Additional Benefits
The PMC Max (HMO-POS) plan offers comprehensive coverage, including no copay for inpatient hospital stays, and coverage for outpatient services with copays ranging from $5 to $50. The plan also includes coverage for ambulance services with no copay, and transportation services for health-related locations. This plan provides coverage for a variety of services such as hearing, vision, and dental, with specific allowances for hearing aids, eyewear, and dental procedures. The plan also covers home health services, and offers additional benefits like over-the-counter items and meal benefits, while requiring prior authorization for some services.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute with no copay for a Medicare-covered stay, and Inpatient Hospital Psychiatric with a $50 copay per admission or stay. Additional Days for Inpatient Hospital-Acute are covered with no copay per day, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered by PMC Max (HMO-POS), including outpatient hospital services with a $25 copay, observation services with a $0-$50 copay, ambulatory surgical center services, and outpatient substance abuse services with a $5 copay for individual and group sessions. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the PMC Max (HMO-POS) plan, but requires prior authorization.
Ambulance and Transportation Services See details
Ambulance Services are covered with no copay and no coinsurance, however, Ground Ambulance Services and Air Ambulance Services are not covered. Transportation Services are covered for plan-approved health-related locations, with 12 one-way trips per year using rideshare services, bus/subway, van, or medical transport, while transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Coverage, are covered by the PMC Max (HMO-POS) plan. Emergency Services have a $75 copay and no coinsurance, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $100 copay and no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The PMC Max (HMO-POS) plan covers primary care physician services, chiropractic services with a $5 copay, occupational therapy services with a $4 copay, and physician specialist services with a $0-$3 copay. Mental health specialty services, psychiatric services, and podiatry services have a $0-$5 copay, and physical therapy and speech-language pathology services have a $4 copay. Opioid Treatment Program Services have a 10% coinsurance.
Preventive Services See details
The PMC Max (HMO-POS) plan covers preventive services, including Medicare-covered preventive services and additional preventive services, with some services requiring prior authorization. The plan does not cover annual physical exams, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers of enrollees, enhanced disease management, and telemonitoring services, or counseling services.
Hearing Services See details
Hearing services under the PMC Max (HMO-POS) plan include routine hearing exams, and fitting/evaluation for hearing aids, with no deductible and no coinsurance. Prescription hearing aids (all types) are covered, with a maximum benefit of $1000 every three years. Prescription hearing aids - Inner Ear, Outer Ear, and Over the Ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams, with no copay, covered once per year, and eyewear. Eyewear has a combined maximum plan benefit coverage of $450 per year, and includes contact lenses and eyeglasses (lenses and frames), while eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The PMC Max (HMO-POS) plan covers a variety of dental services, including oral exams, dental x-rays, and other diagnostic and preventive services, but coverage for some services may be limited to a certain number of visits or a specific periodicity, and orthodontics and maxillofacial prosthetics are not covered. This plan also offers up to $1,500 per year for orthodontic services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the PMC Max (HMO-POS) plan, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs may have coinsurance between 0% and 20%, and Other Medicare Part B Drugs may have a copay between $0 and $10.
Dialysis Services See details
Dialysis Services are covered by the PMC Max (HMO-POS) plan, but require prior authorization. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance between 0% and 10%, but Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies - Non-Medicare benefit is covered with no copay or coinsurance, but Prosthetic Devices and Medical Supplies are not covered. Diabetic Equipment benefits are covered, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for lab services with a coinsurance of at most 20%, and diagnostic radiological services with a copay of at most $25; however, diagnostic procedures/tests, therapeutic radiological services, and outpatient X-ray services are not covered.
Home Health Services See details
Home Health Services are covered by the PMC Max (HMO-POS) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the PMC Max (HMO-POS) plan, but the plan does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but additional days beyond Medicare-covered and non-Medicare-covered stays are not covered. This plan requires prior authorization for SNF services, and there is no cost sharing on the day of discharge.
Other Services See details
The PMC Max (HMO-POS) plan covers over-the-counter (OTC) items with a maximum benefit of $75.00 every month, and also covers meal benefits for a chronic illness, but acupuncture, Dual Eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and other services are not covered. The meal benefit requires prior authorization and a doctor referral.
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