A non-government entity
Providence Medicare Sycamore + Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Providence Medicare Sycamore + Rx (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Providence Medicare Sycamore + Rx (HMO) in 2026, please refer to our full plan details page.
Providence Medicare Sycamore + Rx (HMO) is a HMO plan offered by Providence St Joseph Health available for enrollment in 2025 to people living in Orange County. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Providence Medicare Sycamore + Rx (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 Providence Medicare Sycamore + Rx (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 Providence Medicare Sycamore + Rx (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. Additionally, this plan comes with a Part B Premium reduction of $10.00. You must continue to pay paying your reduced 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 $400.00 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 Providence Medicare Sycamore + Rx (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 Providence Medicare Sycamore + Rx (HMO) plan offers an Enhanced Alternative drug benefit with no prescription drug deductible. During the initial coverage phase, you will pay no copay for Tier 1 preferred generic drugs at preferred pharmacies or through standard mail, while standard pharmacies require a $20 copay. For higher tiers, costs range from a $40 copay for standard generics up to a 33% coinsurance for Tier 4 non-preferred drugs until total drug costs reach $2,100. 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 can reduce their Part D premium to $0.00.
Additional Benefits
The Providence Medicare Sycamore + Rx (HMO) plan offers robust coverage with predictable out-of-pocket costs, featuring no copay and no coinsurance for inpatient hospital stays. Outpatient services and routine preventive care are also highly accessible, requiring no deductible and no copayments for standard preventive visits. For emergency care, members will pay a $150 copay with no coinsurance, which is waived upon hospital admission, while urgent care visits require no copay. Specialty care benefits include one routine eye exam and one routine hearing exam annually with no deductible, though eyewear is not covered. Dental services are covered up to a maximum benefit of $350 every six months, and prescription hearing aids carry a copay between $499.00 and $999.00. For ongoing medical needs, dialysis treatments require a flat $25 copay, while durable medical equipment is subject to a 20% coinsurance with no copay.
Inpatient Hospital See details
Inpatient hospital benefits are partially covered by Providence Medicare Sycamore + Rx (HMO), offering Medicare-covered acute and psychiatric stays with no copay and no coinsurance. Upgrades, non-Medicare-covered stays, and additional days for psychiatric hospitalizations are not covered.
Outpatient Services See details
Outpatient Services are covered by Providence Medicare Sycamore + Rx (HMO), including hospital, observation, ambulatory surgical center, and blood services with no deductible. Individual and group outpatient substance abuse sessions are covered with a $10 copay, though other copayment and coinsurance details are not specified.
Partial Hospitalization See details
Partial hospitalization benefits are covered by Providence Medicare Sycamore + Rx (HMO), though prior authorization is required for these services.
Ambulance and Transportation Services See details
Providence Medicare Sycamore + Rx (HMO) partially covers ambulance and transportation services, as transportation services to health-related locations are not covered. Covered ground and air ambulance services require prior authorization and carry a $100 copay with no coinsurance.
Emergency Services See details
Providence Medicare Sycamore + Rx (HMO) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services are covered with no copay and no coinsurance, while worldwide emergency and emergency transportation services are covered with copays of $150 and $100, respectively, and no coinsurance.
Primary Care See details
Primary Care benefits are covered by Providence Medicare Sycamore + Rx (HMO), including physical therapy and specialist visits, though podiatry is not covered. Chiropractic care is partially covered, excluding routine chiropractic services, and while some mental health and psychiatric services are covered, individual and group sessions are not; specific copay and coinsurance details are not specified.
Preventive Services See details
Preventive services are covered by Providence Medicare Sycamore + Rx (HMO), featuring no copay or coinsurance for Medicare-covered zero-dollar preventive services with prior authorization. Additional preventive benefits are partially covered, excluding health education, in-home safety assessments, PERS, medication reconciliation, readmission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, disease management, telemonitoring, bathroom safety, and counseling. Annual physicals and kidney disease education are also covered.
Hearing Services See details
Hearing services are partially covered by Providence Medicare Sycamore + Rx (HMO), which offers one routine hearing exam annually and unlimited hearing aid fittings with no deductible. Covered prescription hearing aids require a copay between $499.00 and $999.00 with no coinsurance, but OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Providence Medicare Sycamore + Rx (HMO) partially covers vision services, offering one routine eye exam per year with a doctor referral and no deductible, though copay and coinsurance details are not specified. Eyewear benefits, including contact lenses, eyeglasses, lenses, frames, and upgrades, are not covered.
Dental Services See details
Dental services are covered by Providence Medicare Sycamore + Rx (HMO), including preventive, diagnostic, restorative, and orthodontic treatments, up to a maximum benefit of $350 every six months. Medicare-covered dental services are also included but require prior authorization and a doctor referral.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Providence Medicare Sycamore + Rx (HMO) with prior authorization, requiring no copay and no coinsurance to 20% coinsurance for chemotherapy, radiation, and other Part B drugs. Medicare Part B insulin drugs are also covered with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Providence Medicare Sycamore + Rx (HMO) plan, helping you easily manage your kidney care costs. Covered individuals will pay a flat $25 copay per treatment with no coinsurance.
Medical Equipment See details
Providence Medicare Sycamore + Rx (HMO) partially covers medical equipment, featuring no copay and a 20% coinsurance for durable medical equipment, prosthetic devices, and medical supplies. Under this plan, diabetic supplies and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered under Providence Medicare Sycamore + Rx (HMO), though diagnostic procedures, lab services, diagnostic radiological services, and outpatient X-ray services are not covered. Covered therapeutic radiological services require prior authorization and carry a $50 copay with no coinsurance.
Home Health Services See details
Home Health Services are covered by Providence Medicare Sycamore + Rx (HMO), but prior authorization is required. Specific copay and coinsurance information is not specified for this benefit.
Cardiac Rehabilitation Services See details
Providence Medicare Sycamore + Rx (HMO) does not cover Cardiac Rehabilitation Services. This includes cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services, none of which are covered under this plan.
Skilled Nursing Facility (SNF) See details
Providence Medicare Sycamore + Rx (HMO) partially covers Skilled Nursing Facility (SNF) services with prior authorization, though additional days beyond the Medicare-covered limit are not covered. Covered stays require no copay for days 1 through 20 and a $100 daily copay for days 21 through 100, with no coinsurance.
Other Services See details
Other Services are partially covered by Providence Medicare Sycamore + Rx (HMO), which provides a limited-duration meal benefit for chronic illnesses with no maximum limit. Acupuncture, over-the-counter (OTC) items, and highly integrated dual-eligible SNP services are not covered, and specific copay or coinsurance details for the meal benefit are not specified.
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