A non-government entity
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 2026, 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 2026.
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 a $250.00 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 $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:
Sign up for UCLA Health Medicare Advantage Principal Plan (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The UCLA Health Medicare Advantage Principal Plan (HMO) features an Enhanced Alternative drug benefit with a $250 prescription drug deductible. During the initial coverage phase, which lasts until total drug costs reach $2,100, you will pay no copay for Tier 1 preferred generic drugs through standard pharmacies or standard mail. For other tiers, standard pharmacy and mail-order costs include a $47 copay for Tier 2 standard generics, 45% coinsurance for Tier 3 preferred brands, and 30% coinsurance for Tier 4 non-preferred drugs. Once your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for covered Part D drugs. Additionally, beneficiaries who qualify for the low-income subsidy, also known as Extra Help, will see their Part D costs reduced to $0.
Additional Benefits
The UCLA Health Medicare Advantage Principal Plan (HMO) offers comprehensive medical coverage with predictable out-of-pocket costs, including a $200 copay per stay and no coinsurance for inpatient hospital admissions. Outpatient hospital services feature affordable options ranging from no copay up to $100, while emergency room visits carry a $150 copay that is waived if you are admitted. Routine preventive care and annual physical exams are fully covered with no copay or coinsurance, helping you manage your health proactively. Essential ancillary benefits are also included, featuring no-copay routine hearing and vision exams, alongside covered dental procedures with no coinsurance. While durable medical equipment and dialysis require a 20% coinsurance, members enjoy no copay for the first 20 days of skilled nursing facility care and a $60 quarterly allowance for over-the-counter items. However, some services like cardiac rehabilitation and routine podiatry are not covered by this plan.
Inpatient Hospital See details
Inpatient hospital benefits are partially covered by the UCLA Health Medicare Advantage Principal Plan (HMO), featuring a $200 copay per stay and no coinsurance for Medicare-covered acute and psychiatric admissions. While unlimited additional days for acute stays are covered at a $200 copay, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
UCLA Health Medicare Advantage Principal Plan (HMO) covers outpatient services with no coinsurance, although prior authorization and referrals are generally required. Outpatient hospital services feature copays ranging from no copay up to $100, while outpatient substance abuse sessions require a $15 copay.
Partial Hospitalization See details
Partial hospitalization benefits are covered by the UCLA Health Medicare Advantage Principal Plan (HMO) with a $50.00 copay and no coinsurance. These covered services require prior authorization and a doctor referral.
Ambulance and Transportation Services See details
UCLA Health Medicare Advantage Principal Plan (HMO) covers ambulance services and partially covers transportation services. Ground ambulance services require a $200 copay and no coinsurance, while air ambulance services carry a 20% coinsurance and no copay. Transportation includes up to 12 one-way trips per year to plan-approved locations via bus or subway with no copay or coinsurance, but transportation to any health-related location is not covered.
Emergency Services See details
Emergency services are covered by the UCLA Health Medicare Advantage Principal Plan (HMO) with a $150 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 36 hours. Urgently needed services require a $15 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to a $50,000 maximum with copays ranging from $50 to $200.
Primary Care See details
UCLA Health Medicare Advantage Principal Plan (HMO) provides partially covered Primary Care benefits, as podiatry services are not covered. Covered services like mental health, psychiatric, and opioid treatment services require a $15 copay and no coinsurance, with most specialty services requiring prior authorization and a doctor referral.
Preventive Services See details
UCLA Health Medicare Advantage Principal Plan (HMO) covers Medicare-covered zero-dollar preventive services and annual physical exams with no copay or coinsurance. Additional preventive services are partially covered, excluding health education, safety assessments, PERS, medical nutrition therapy, wigs, weight management, alternative therapies, therapeutic massage, adult day health, palliative care, caregiver support, smoking cessation, disease management, telemonitoring, remote access, home safety devices, and counseling. Kidney disease education and other screenings are also covered but require prior authorization and referrals.
Hearing Services See details
Hearing services are partially covered by the UCLA Health Medicare Advantage Principal Plan (HMO), providing one annual routine exam and fitting evaluation with no copay, coinsurance, or deductible. Up to two prescription hearing aids are covered per year with a copay of $295 to $1,495 and no coinsurance, while inner ear, outer ear, over-the-ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
UCLA Health Medicare Advantage Principal Plan (HMO) offers partially covered vision services with no deductible, though copay and coinsurance information is not specified. The plan covers one routine eye exam per year, contact lenses, and eyeglasses (lenses and frames) up to a $150 annual limit, while individual eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
UCLA Health Medicare Advantage Principal Plan (HMO) partially covers dental services, featuring no coinsurance and copays ranging from no copay up to $656 depending on the procedure. While preventive care, exams, and various restorative treatments are covered, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
UCLA Health Medicare Advantage Principal Plan (HMO) covers home infusion bundled services with no copay and coinsurance ranging from no coinsurance up to 20% for chemotherapy, radiation, and other Part B drugs. Prior authorization is required, step therapy applies, and Medicare Part B insulin drugs are also covered.
Dialysis Services See details
Dialysis Services are covered under the UCLA Health Medicare Advantage Principal Plan (HMO) with a 20% coinsurance and no copay. Prior authorization and a doctor referral are required to receive these covered services.
Medical Equipment See details
UCLA Health Medicare Advantage Principal Plan (HMO) partially covers medical equipment with no copays, though diabetic therapeutic shoes and inserts are not covered. Durable medical equipment requires a 20% to 50% coinsurance, while prosthetic devices, medical supplies, and diabetic supplies range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
UCLA Health Medicare Advantage Principal Plan (HMO) partially covers Diagnostic and Radiological Services, though diagnostic procedures, tests, lab services, and outpatient X-ray services are not covered. Covered diagnostic radiological services require no coinsurance and a copay ranging from no copay to $50, while therapeutic radiological services require a copay and 20% coinsurance. Prior authorization and a doctor referral are required for all covered services.
Home Health Services See details
Home Health Services are covered by the UCLA Health Medicare Advantage Principal Plan (HMO), but require prior authorization and a doctor referral. While specific copay and coinsurance costs are not listed in the plan benefits, these services are fully covered for eligible members meeting the referral requirements.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the UCLA Health Medicare Advantage Principal Plan (HMO) because although some services are covered in theory, in practice Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD services are all not covered, leaving members with no copay or coinsurance.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the UCLA Health Medicare Advantage Principal Plan (HMO) with prior authorization and a doctor referral, though additional days beyond the Medicare-covered limit are not covered. There is no copay or coinsurance for days 1 through 20, while days 21 through 100 require a $100 daily copay and no coinsurance.
Other Services See details
Other Services are partially covered by the UCLA Health Medicare Advantage Principal Plan (HMO), excluding Dual Eligible SNPs with Highly Integrated Services. This benefit includes up to 12 acupuncture treatments yearly, chronic illness meal benefits with a doctor's referral, and a $60 quarterly over-the-counter allowance, although nicotine replacement therapy and naloxone are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved