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Elevance Health, Inc.

Plan ID: H4003-19-0

MMM Unico (HMO-POS)

2025 MMM Unico (HMO-POS) H4003 — 019 — 0 is a Medicare Advantage plan with drug coverage. It has received a 4.5-out-of-5 star rating from CMS for 2025.

Learn more about MMM Unico (HMO-POS) H4003 - 019 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

4.5 / 5 stars for 2025

$15.00 /mo

Monthly premium

Drug deductible

$3250.00

Out-of-pocket maximum

Enroll online

Call to enroll

Get personalized help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!

Overview Benefits & Costs Drug Coverage Additional Benefits

Plan Overview

2025 MMM Unico (HMO-POS) H4003 — 019 — 0 is a HMO-POS offered in Puerto Rico by Elevance Health, Inc.. It has a monthly premium of $15.00.

Premium Breakdown

Standard Part B Premium

$185.00

Part B premium reduction

- $0

Monthly Plan Premium

$15.00

Total Premium:

$200.00

Note:

The standard Medicare Part B premium for 2025 is $185.00. Your premium may differ based on factors like late enrollment, income (IRMAA), or disability status. Most people enrolled in Medicare Part B are required to pay this premium.

Special needs plan type

Out-of-pocket maximum

$3250.00

Plan Organization:

Elevance Health, Inc.

Plan Type:

HMO-POS

Location:

Puerto Rico

Drugs Covered:

Yes

Drug Formulary:

Formulary Link

Pharmacies:

Pharmacies Link

Doctor Choice:

Doctors Link:

Doctors Link

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Drug deductible

Sign up for MMM Unico (HMO-POS)

Enroll online

Call to enroll

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

MMM Unico (HMO-POS) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Benefit Type

Enhanced Alternative

Prescription drug deductible

Part D Premium Reduction

This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.

Part D	LIS Full
$0.00	$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2000.00. Once you reach that amount, you will enter the next coverage phase.

30 Days

60 Days

90 Days

Tier	Preferred Pharmacy	Standard Pharmacy	Preferred Mail	Standard Mail
1. Preferred Generic	-	-	-	-
2. Standard Generic	-	-	-	-
3. Preferred Brand	-	-	-	-
4. Non-Preferred Drug	-	-	-	-
5. Specialty Tier	-	-	-	-

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.

Additional Benefits

MMM Unico (HMO-POS) also provides the following benefits.

Note:

Limits, Authorizations, and Referrals may apply for the benefits below. Contact the plan for details.

Comprehensive dental

Adjunctive General Services

In-Network: No Coins - No Co pay

Out-Of-Network: 20% Coins - No Copay

Endodontics

In-Network: No Coins - No Co pay

Out-Of-Network: 20% Coins - No Copay

Implant Services

In-Network: No Coins - No Co pay

Out-Of-Network: 20% Coins - No Copay

Oral and Maxillofacial Surgery

In-Network: No Coins - No Co pay

Out-Of-Network: 20% Coins - No Copay

Periodontics

In-Network: No Coins - No Co pay

Out-Of-Network: 20% Coins - No Copay

Prosthodontics, fixed

In-Network: No Coins - No Co pay

Out-Of-Network: 20% Coins - No Copay

Prosthodontics, removable

In-Network: No Coins - No Co pay

Out-Of-Network: 20% Coins - No Copay

Restorative Services

In-Network: No Coins - No Co pay

Out-Of-Network: 20% Coins - No Copay

Preventive dental

Dental X-Rays

In-Network: No Coins - No Copay

Out-Of-Network: 20% Coins - No Copay

Fluoride Treatment

In-Network: No Coins - No Copay

Out-Of-Network: 20% Coins - No Copay

Oral Exams

In-Network: No Coins - No Copay

Out-Of-Network: 20% Coins - No Copay

Other Diagnostic Dental Services

In-Network: No Coins - No Copay

Out-Of-Network: 20% Coins - No Copay

Other Preventive Dental Services

In-Network: No Coins - No Copay

Out-Of-Network: 20% Coins - No Copay

Prophylaxis (cleaning)

In-Network: No Coins - No Copay

Out-Of-Network: 20% Coins - No Copay

Diagnostic procedures/lab services/imaging

Diagnostic radiology services

Diagnostic tests and procedures

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Outpatient x-rays

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Lab services

In-Network: 0-20% coinsurance

Out-Of-Network: 20% coinsurance

Doctor visits

Primary

In-Network: $0 copay

Out-Of-Network: 20% coinsurance per visit

Specialist

In-Network: $0 copay

Out-Of-Network: 20% coinsurance per visit

Emergency care/Urgent care

Urgent care

$0 copay

Emergency

$25 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Routine foot care

In-Network: $0 copay

Ground ambulance

All service types

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Hearing

Hearing aids

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Hearing aids OTC

Not covered

Medicare-Covered Hearing Exam

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Fitting/evaluation

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Inpatient hospital coverage

All service types

In-Network: Tier 1 $0 copay per stay Tier 2 $50 per stay

Out-Of-Network: 20% per stay

Outpatient hospital coverage

All service types

In-Network: $25 copay per visit

Out-Of-Network: 20% coinsurance per visit

Optional benefits

All service types

Medical equipment/supplies

Diabetes supplies

In-Network: $0 copay

Out-Of-Network: 20% coinsurance per item

Prosthetics

Durable medical equipment

Medicare Part B drugs

Chemotherapy

In-Network: 0-20% coinsurance

Out-Of-Network: 20% coinsurance

Other Part B drugs

In-Network: $0-5 copay or 0-20% coinsurance

Out-Of-Network: 20% coinsurance

Mental health services

Outpatient group therapy visit

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Outpatient group therapy visit with a psychiatrist

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Inpatient hospital - psychiatric

In-Network: $50 per stay

Out-Of-Network: 20% per stay

Outpatient individual therapy visit with a psychiatrist

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Outpatient individual therapy visit

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Preventive care

All service types

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Rehabilitation services

Physical therapy and speech and language therapy visit

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Occupational therapy visit

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Skilled Nursing Facility

All service types

In-Network: $0 copay

Out-Of-Network: 20% per stay

Transportation

All service types

In-Network: $0 copay

Vision

Contact lenses

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Upgrades

Not covered

Eyeglass frames

Not covered

Eyeglass lenses

Not covered

Eyeglasses (frames and lenses)

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Other

Not covered

Routine eye exam

In-Network: $0 copay

Out-Of-Network: 20% coinsurance

Wellness programs (eg, fitness, nursing hotline)

All service types

Covered

Plan Providers

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.

Get Personalized Help from a licensed insurance agent

1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

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SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M

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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.

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