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UCLA Health Medicare Advantage Principal Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for UCLA Health Medicare Advantage Principal Plan (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on UCLA Health Medicare Advantage Principal Plan (HMO) in 2025, please refer to our full plan details page.
UCLA Health Medicare Advantage Principal Plan (HMO) is a HMO plan offered by The Regents of the University of California available for enrollment in 2025 to people living in Los Angeles County. The overall rating for this plan is not yet available for 2025.
It's important to know that UCLA Health Medicare Advantage Principal Plan (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 UCLA Health Medicare Advantage Principal Plan (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 UCLA Health Medicare Advantage Principal Plan (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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $2499.00 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:
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Drug Coverage
The UCLA Health Medicare Advantage Principal Plan (HMO) has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay either a copay or coinsurance depending on the drug tier and the pharmacy used. For preferred and standard generic drugs, there is either no copay or a $47 copay. For preferred brand drugs, you pay 45% coinsurance, and for non-preferred drugs, you pay 33% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The UCLA Health Medicare Advantage Principal Plan (HMO) offers a variety of benefits, including inpatient hospital stays with a $200 copay, outpatient services with varying copays, and emergency services with a $140 copay. The plan also covers primary care, preventive services, and offers dental, vision, and hearing services. Additional benefits include ambulance services with a copay or coinsurance, and home health services with no copay. The plan also covers some medical equipment with coinsurance, and home infusion services with coinsurance. While some services like skilled nursing facilities and dialysis require prior authorization, this plan offers a wide range of coverage for your healthcare needs.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered by the UCLA Health Medicare Advantage Principal Plan (HMO). For Medicare-covered stays, you will pay a $200 copay per admission or stay, while additional days for inpatient hospital-acute will have a $200 copay for days 91-999. Non-Medicare-covered stays and upgrades for inpatient hospital acute and additional days for inpatient hospital psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered, including outpatient hospital services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a copay between $0 and $100, and individual and group substance abuse sessions have a $15 copay.
Partial Hospitalization See details
Partial Hospitalization is covered, requiring prior authorization and a doctor referral. The copay for this benefit is $50.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the UCLA Health Medicare Advantage Principal Plan (HMO). Ground ambulance services have a $200 copay, while air ambulance services have a 20% coinsurance. Transportation Services to a plan-approved health-related location are covered for up to 12 one-way trips per year via bus or subway, but transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the UCLA Health Medicare Advantage Principal Plan (HMO). Emergency Services have a $140 copay, and Urgently Needed Services have a $15 copay, while Worldwide Emergency Coverage has a $140 copay, Worldwide Urgent Coverage has a $50 copay, and Worldwide Emergency Transportation has a $200 copay.
Primary Care See details
The UCLA Health Medicare Advantage Principal Plan (HMO) covers primary care physician services, chiropractic services (with a limit of 12 visits per year), occupational therapy services, physician specialist services, mental health specialty services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Individual and group sessions for mental health and psychiatric services have a copay of $15.00 per session.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, annual physical exams, and additional preventive services, some of which require prior authorization and a doctor referral. The plan also covers In-Home Safety Assessments, Personal Emergency Response Systems, Nutritional/Dietary Benefits, In-Home Support Services, Support for Caregivers of Enrollees, Fitness Benefits (Memory Fitness), Remote Access Technologies, Kidney Disease Education Services, Glaucoma Screenings, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKGs following a Welcome Visit. However, Health Education, Medical Nutrition Therapy, 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, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, Counseling Services, and Additional Sessions of Smoking and Tobacco Cessation Counseling are not covered.
Hearing Services See details
Hearing services include routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams and fitting/evaluation for hearing aids are covered once per year. Prescription hearing aids (all types) are covered with a copay between $295 and $1495, twice per year, while prescription hearing aids - inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services are covered, including routine eye exams with one visit per year, and eyewear with a combined maximum of $150 per year. Contact lenses and eyeglasses (lenses and frames) are also covered. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and fluoride treatment. Restorative services have a copay of $7-$410, adjunctive general services have a copay of $0-$64, endodontics have a copay of $12-$154, periodontics have a copay of $0-$130, prosthodontics removable have a copay of $16-$656, prosthodontics fixed have a copay of $42-$412, and oral and maxillofacial surgery has a copay of $3-$152. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B insulin drugs, and other Medicare Part B drugs. Coinsurance for Medicare Part B Chemotherapy/Radiation Drugs and other Medicare Part B drugs is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the UCLA Health Medicare Advantage Principal Plan (HMO), but require prior authorization and a doctor referral. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a coinsurance between 20% and 50%, while Prosthetic Devices have a coinsurance between 0% and 20%; Medical Supplies have a 20% coinsurance. Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the UCLA Health Medicare Advantage Principal Plan (HMO). Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered, while Diagnostic Radiological Services have a copay of up to $50, and Therapeutic Radiological Services have a coinsurance of 20%.
Home Health Services See details
Home Health Services are covered by the UCLA Health Medicare Advantage Principal Plan (HMO) with no copay and no coinsurance, but require authorization and a referral. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the UCLA Health Medicare Advantage Principal Plan (HMO). Prior authorization and a doctor referral are required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the UCLA Health Medicare Advantage Principal Plan (HMO), but require prior authorization and a doctor's referral. For days 1-20, there is no copay, and for days 21-100, the copay is $100 per day; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The UCLA Health Medicare Advantage Principal Plan (HMO) covers acupuncture, with a limit of 12 treatments per year, and over-the-counter (OTC) items, with a maximum benefit of $50.00 every three months. Meal benefits are covered with prior authorization and a doctor referral. Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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