A non-government entity
DLP Marquette Health Plan, LLC
Plan ID: H3127-1-0
Plan Summary PageUpper Peninsula Health Plan MI Coordinated Health (HMO D-SNP)
2026 Upper Peninsula Health Plan MI Coordinated Health (HMO D-SNP) H3127 — 001 — 0 is a Medicare Advantage plan with drug coverage.
Learn more about Upper Peninsula Health Plan MI Coordinated Health (HMO D-SNP) H3127 - 001 - 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.
$8.80 /mo
Monthly premium
$615.00
Drug deductible
$9250.00
Out-of-pocket maximum (Out-of-Network)
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About This Plan
The Upper Peninsula Health Plan MI Coordinated Health (HMO D-SNP) provides comprehensive coverage for core medical needs, with many essential services requiring no copay. You will pay no copay and no coinsurance for inpatient hospital stays, home health services, skilled nursing facility care, and preventive screenings. For outpatient hospital visits, primary and specialist care, emergency services, and diagnostic tests, the plan typically charges no copay but requires a twenty percent coinsurance. While Medicare-covered dental care and diagnostic hearing exams are available, this plan does not cover routine dental, vision, or hearing services, including eyeglasses and hearing aids. Essential medical equipment, diabetes supplies, and dialysis are covered with no copay and a twenty percent coinsurance. Additionally, members benefit from a forty-two dollar monthly allowance with no copay for over-the-counter items to help manage daily health needs.
The Upper Peninsula Health Plan MI Coordinated Health (HMO D-SNP) features an annual prescription drug deductible of $615. You will need to pay this deductible amount out-of-pocket for your covered medications before the plan begins to pay its share. Specific drug coverage tier details, including copayments and coinsurance for individual formulary tiers, are not currently available for this plan. For detailed information on how your specific medications are covered, it is recommended to contact the plan directly.
Plan data sourced from the official CMS 2026 public benefit files. Reviewed by Walt Whitney. How we source and review plan information.
Plan Overview
2026 Upper Peninsula Health Plan MI Coordinated Health (HMO D-SNP) H3127 — 001 — 0 is a HMO D-SNP offered in Upper Peninsula of Michigan by DLP Marquette Health Plan, LLC. It has a monthly premium of $8.80.
Important:
2026 Upper Peninsula Health Plan MI Coordinated Health (HMO D-SNP) H3127 — 001 — 0 is a Dual-Eligible Special Needs Type plan. You can only enroll in this plan if you meet specific criteria.
Premium Breakdown
Monthly plan premium
$8.80
Standard Part B premium
$202.90
Note:
The standard Medicare Part B premium for 2026 is $202.90. Your actual Part B premium may differ based on income (IRMAA), late enrollment penalties, Medicaid assistance, disability status, or other factors. Most people enrolled in Medicare Part B are required to pay this premium.
Special needs plan type
Yes
Out-of-pocket maximum (In-Network)
N/A
Out-of-pocket maximum (Out-of-Network)
$9250.00
Out-of-pocket maximum (Combined)
N/A
Conditions Covered
None
Plan Organization:
DLP Marquette Health Plan, LLC
Plan Type:
HMO D-SNP
Location:
Upper Peninsula of Michigan
Drugs Covered:
Yes
Drug Formulary:
Pharmacies:
Doctors Link:
Deductibles
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Drug deductible
$615
Note:
This plan does not charge an annual deductible for all drugs. The $615.00 annual deductible only applies to drugs in certain tiers.
Sign up for Upper Peninsula Health Plan MI Coordinated Health (HMO D-SNP)
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
Upper Peninsula Health Plan MI Coordinated Health (HMO D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Benefit Type
Defined Standard
Prescription drug deductible
$615.00
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 |
|---|---|
$8.80 | $8.80 |
Initial Coverage Phase
After you pay your $615.00 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 $2100.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Preferred Pharmacy | Standard Pharmacy | Preferred Mail | Standard Mail |
|---|
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2100.00, 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
Upper Peninsula Health Plan MI Coordinated Health (HMO D-SNP) also provides the following benefits.
Inpatient Hospital
Inpatient Hospital benefits are covered.
Inpatient Hospital-Acute
Inpatient Hospital-Acute benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Do you charge the Medicare-defined cost share for tier 1?
Yes
Periodicity
Original Medicare
Additional Days for Inpatient Hospital-Acute
Not covered.
Non-Medicare-covered Stay for Inpatient Hospital-Acute
Not covered.
Upgrades for Inpatient Hospital-Acute
Not covered.
Inpatient Hospital Psychiatric
Inpatient Hospital Psychiatric benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Do you charge the Medicare-defined cost share for tier 1?
Yes
Periodicity
Original Medicare
Additional Days for Inpatient Hospital Psychiatric
Not covered.
Non-Medicare-covered Stay for Inpatient Hospital Psychiatric
Not covered.
Outpatient Services
Outpatient Services benefits are covered.
All Outpatient Hospital Services
All Outpatient Hospital Services benefits are covered.
Cost Sharing:
More Details:
Which Services have a Coinsurance
Medicare-covered Outpatient Hospital Services, Medicare-covered Observation Services
Outpatient Hospital Services
Outpatient Hospital Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Observation Services
Observation Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Ambulatory Surgical Center (ASC) Services
Ambulatory Surgical Center (ASC) Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Outpatient Substance Abuse Services
Outpatient Substance Abuse Services benefits are covered.
Cost Sharing:
More Details:
Which Outpatient Substance Abuse services have a Coinsurance
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Outpatient Substance Abuse
Individual Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Group Sessions for Outpatient Substance Abuse
Group Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Outpatient Blood Services
Outpatient Blood Services benefits are covered.
Cost Sharing:
More Details:
Is there a deductible?
No
Do you waive the deductible for the first three pints of blood?
Yes
Partial Hospitalization
Partial Hospitalization benefits are covered.
Partial Hospitalization
Partial Hospitalization benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Coinsurance percent
20
Partial Hospitalization
Partial Hospitalization benefits are covered.
Cost Sharing:
More Details:
Coinsurance percent
20
Ambulance and Transportation Services
Ambulance and Transportation Services benefits are covered.
All Ambulance Services
All Ambulance Services benefits are covered.
More Details:
Is there a coinsurance?
Yes
Which Services have a Coinsurance
Medicare-covered Ground Ambulance Services, Medicare-covered Air Ambulance Services
Is this Coinsurance waived if admitted to hospital?
No
Is there a copayment ?
No
Ground Ambulance Services
Ground Ambulance Services benefits are covered.
Cost Sharing:
Air Ambulance Services
Air Ambulance Services benefits are covered.
Cost Sharing:
Transportation Services
Transportation Services benefits are covered.
Transportation Services - Plan Approved Health-related Location
Not covered.
Transportation Services - Any Health-related Location
Not covered.
Emergency Services
Emergency Services benefits are covered.
Emergency Services
Emergency Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
Yes
Is the coinsurance for Medicare-covered benefits waived if admitted to hospital?
Yes
Select either days or hours within which admission must occur for waiver
Hours
Enter number of days or hours
24
Is there a copayment?
No
Maximum per visit amount
115.00
Does the cost sharing count towards any plan-level deductible?
Yes
Urgently Needed Services
Urgently Needed Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
Yes
Is the coinsurance for Medicare-covered benefits waived if admitted to hospital?
No
Is there a copayment?
No
Maximum per visit amount
40.00
Does the cost sharing count towards any plan-level deductible?
Yes
Worldwide Emergency Services
Worldwide Emergency Services benefits are covered.
Worldwide Emergency Coverage
Not covered.
Worldwide Urgent Coverage
Not covered.
Worldwide Emergency Transportation
Not covered.
Primary Care
Primary Care benefits are covered.
Primary Care Physician Services
Primary Care Physician Services benefits are covered.
Cost Sharing:
Chiropractic Services
Chiropractic Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Chiropractic Services have a Coinsurance
Routine Care
Routine Chiropractic Care
Not covered.
Occupational Therapy Services
Occupational Therapy Services benefits are covered.
Cost Sharing:
Physician Specialist Services
Physician Specialist Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Mental Health Specialty Services
Mental Health Specialty Services benefits are covered.
Cost Sharing:
More Details:
Which Mental Health Specialty Services have a Coinsurance
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Mental Health Specialty Services
Individual Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Group Sessions for Mental Health Specialty Services
Group Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Podiatry Services
Not covered.
Other Health Care Professional
Other Health Care Professional benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Psychiatric Services
Psychiatric Services benefits are covered.
Cost Sharing:
More Details:
Which Psychiatric Services have a Coinsurance
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Psychiatric Services
Individual Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Group Sessions for Psychiatric Services
Group Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Physical Therapy and Speech-Language Pathology Services
Physical Therapy and Speech-Language Pathology Services benefits are covered.
Cost Sharing:
Additional Telehealth Benefits
Additional Telehealth Benefits benefits are covered.
Opioid Treatment Program Services
Opioid Treatment Program Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Preventive Services
Preventive Services benefits are covered.
Medicare-covered Zero Dollar Preventive Services
Medicare-covered Zero Dollar Preventive Services benefits are covered.
Annual Physical Exam
Not covered.
Additional Preventive Services
Additional Preventive Services benefits are covered.
Health Education
Not covered.
In-Home Safety Assessment
Not covered.
Personal Emergency Response System (PERS)
Not covered.
Medical Nutrition Therapy (MNT)
Not covered.
Post discharge In-Home Medication Reconciliation
Not covered.
Re-admission Prevention
Not covered.
Wigs for Hair Loss Related to Chemotherapy
Not covered.
Weight Management Programs
Not covered.
Alternative Therapies
Not covered.
Therapeutic Massage
Not covered.
Adult Day Health Services
Not covered.
Nutritional/Dietary Benefit
Not covered.
Home-Based Palliative Care
Not covered.
In-Home Support Services
Not covered.
Support for Caregivers of Enrollees
Not covered.
Additional Sessions of Smoking and Tobacco Cessation Counseling
Not covered.
Fitness Benefit
Not covered.
Enhanced Disease Management
Not covered.
Telemonitoring Services
Not covered.
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)
Not covered.
Home and Bathroom Safety Devices and Modifications
Not covered.
Counseling Services
Not covered.
Kidney Disease Education Services
Kidney Disease Education Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
0.00
Maximum copayment
0.00
Other Preventive Services
Other Preventive Services benefits are covered.
More Details:
Is a referral required for any Services?
No
Glaucoma Screening
Glaucoma Screening benefits are covered.
Diabetes Self-Management Training
Diabetes Self-Management Training benefits are covered.
Digital Rectal Exams
Digital Rectal Exams benefits are covered.
EKG following Welcome Visit
EKG following Welcome Visit benefits are covered.
Hearing Services
Hearing Services benefits are covered.
Hearing Exams
Hearing Exams benefits are covered. A doctor referral is required.
Cost Sharing:
More Details:
Which Hearing Exam Benefits have a Coinsurance
Routine Hearing Exams
Minimum coinsurance
20
Is there a deductible?
No
Routine Hearing Exams
Not covered.
Fitting/Evaluation for Hearing Aid
Not covered.
Prescription Hearing Aids
Prescription Hearing Aids benefits are covered.
Prescription Hearing Aids (all types)
Not covered.
Prescription Hearing Aids - Inner Ear
Not covered.
Prescription Hearing Aids - Outer Ear
Not covered.
Prescription Hearing Aids - Over the Ear
Not covered.
OTC Hearing Aids
Not covered.
Vision Services
Vision Services benefits are covered.
Eye Exams
Eye Exams benefits are covered.
Cost Sharing:
More Details:
Which Eye Exams have a Coinsurance
Routine Eye Exams
Is there a deductible?
No
Routine Eye Exams
Not covered.
Eyewear
Eyewear benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Eyewear Benefits have a Coinsurance
Contact lenses
Is there a deductible?
No
Contact Lenses
Not covered.
Eyeglasses (lenses and frames)
Not covered.
Eyeglass lenses
Not covered.
Eyeglass frames
Not covered.
Upgrades
Not covered.
Dental Services
Dental Services benefits are covered.
Medicare Dental Services
Medicare Dental Services benefits are covered.
Cost Sharing:
More Details:
Coinsurance percentage
20
Orthodontic Services
Not covered.
Restorative Services
Not covered.
Adjunctive General Services
Not covered.
Endodontics
Not covered.
Periodontics
Not covered.
Prosthodontics, removable
Not covered.
Maxillofacial Prosthetics
Not covered.
Implant Services
Not covered.
Prosthodontics, fixed
Not covered.
Oral and Maxillofacial Surgery
Not covered.
Orthodontics
Not covered.
Home Infusion bundled Services
Home Infusion bundled Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Medicare Part B Rx Drugs have a Coinsurance
Medicare Part B Chemotherapy/Radiation Drugs, Other Medicare Part B Drugs
Does this plan have a service specific maximum enrollee out-of-pocket cost (MOOP)?
No
Does the plan offer step therapy?
No
Insulin
Insulin benefits are covered.
Medicare Part B Insulin Drugs
Medicare Part B Insulin Drugs benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Does the Part B drugs - Insulin cost sharing count towards any plan-level deductible?
No
Medicare Part B Chemotherapy/Radiation Drugs
Medicare Part B Chemotherapy/Radiation Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Other Medicare Part B Drugs
Other Medicare Part B Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Dialysis Services
Dialysis Services benefits are covered. A doctor referral is required.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Equipment
Medical Equipment benefits are covered.
Durable Medical Equipment (DME)
Durable Medical Equipment (DME) benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Are there preferred vendors/manufacturers for Durable Medical Equipment (DME)?
No
Prosthetics/Medical Supplies - Non-Medicare benefit
Prosthetics/Medical Supplies - Non-Medicare benefit benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Prosthetics/Medical Supplies have a Coinsurance
Medicare-covered Prosthetic Devices, Medicare-covered Medical Supplies
Prosthetic Devices
Prosthetic Devices benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Supplies
Medical Supplies benefits are covered.
Cost Sharing:
Diabetic Equipment
Diabetic Equipment benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Diabetic Supplies and Services have a Coinsurance
Medicare-covered Diabetic Supplies, Medicare-covered Diabetic Therapeutic Shoes or Inserts
Do you limit Diabetic supplies and services to those from specified manufacturers
No
Diabetic Supplies
Diabetic Supplies benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Diabetic Therapeutic Shoes/Inserts
Diabetic Therapeutic Shoes/Inserts benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Diagnostic and Radiological Services
Diagnostic and Radiological Services benefits are covered.
All Diagnostic services
All Diagnostic services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Which Outpatient Diagnostic Procedures/Tests/Lab Services have a Coinsurance
Medicare-covered Diagnostic Procedures/Tests, Medicare-covered Lab Services
Is there a copayment?
No
Diagnostic Procedures/Tests
Diagnostic Procedures/Tests benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Lab Services
Lab Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
All Radiological Services
All Radiological Services benefits are covered.
Cost Sharing:
More Details:
Which Outpatient Diagnostic/Therapeutic Radiological Services have a Coinsurance
Medicare-covered Diagnostic Radiological Services, Medicare-covered Therapeutic Radiological Services, Medicare-covered X-Ray Services
Is there a copayment?
No
Diagnostic Radiological Services
Diagnostic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Therapeutic Radiological Services
Therapeutic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Outpatient X-Ray Services
Outpatient X-Ray Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Home Health Services
Home Health Services benefits are covered. A doctor referral is required.
Cost Sharing:
Cardiac Rehabilitation Services
Cardiac Rehabilitation Services benefits are covered. A doctor referral is required.
Cost Sharing:
More Details:
Which Cardiac and Pulmonary Rehabilitation Services have a Coinsurance
Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, Additional Cardiac Rehabilitation Services
Cardiac Rehabilitation Services
Not covered.
Intensive Cardiac Rehabilitation Services
Not covered.
Pulmonary Rehabilitation Services
Not covered.
SET for PAD Services
Not covered.
Skilled Nursing Facility (SNF)
Skilled Nursing Facility (SNF) benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Does the plan provide Skilled Nursing Facility Services as a supplemental benefit under Part C?
Yes
Do you allow less than 3 day inpatient hospital stay prior to SNF admission?
Yes
Days
Zero
Do you charge the Medicare-defined cost share for tier 1?
Yes
Periodicity
Original Medicare
Additional Days beyond Medicare-covered for Skilled Nursing Facility (SNF)
Not covered.
Other Services
Other Services benefits are covered.
Acupuncture
Not covered.
Over-the-Counter (OTC) Items
Over-the-Counter (OTC) Items benefits are covered.
More Details:
Does the plan provide Over-The-Counter (OTC) Items as a supplemental benefit under Part C?
Yes
Is there a maximum plan benefit coverage amount?
Yes
Maximum plan benefit coverage amount
42.00
Periodicity
Every month
Does your Maximum Plan Benefit Coverage amount carry forward to the next period if it is unused?
Yes
Plan offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit?
No
Plan offers Naloxone coverage as a Part C OTC benefit?
Yes
Does this cover all of the drugs on the CMS OTC list which may be found in Chapter 4 of the Medicare Managed Care Manual
Yes
Indicate mode of delivery for the OTC Items
Reimbursement
Meal Benefit
Not covered.
Dual Eligible SNPs with Highly Integrated Services
Not 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.
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