2027 Medicare Advantage plan

MMM Plenitud (HMO-POS): 2027 benefits and costs

Medicare y Mucho Mas (MMM) HMO-POS

CMS plan ID: H4004-065-0 · Plan year: 2027

MMM Plenitud (HMO-POS) is a 2027 Medicare Advantage plan offered by Medicare y Mucho Mas (MMM). It is listed in Puerto Rico.

2027 plan costs at a glance

Monthly plan premium$0.00

Drug deductible$0.00

In-network medical out-of-pocket maximum$3,250.00

Organization: Medicare y Mucho Mas (MMM)
Plan organization: MMM HEALTHCARE, LLC
Parent company: Elevance Health, Inc.
Plan type: HMO-POS
Part C premium: $0.00
Part D premium: $0.00
Prescription drug coverage: Yes
2027 CMS Star Rating

Standard monthly Medicare Part B premium: $209.50 (estimated)
Monthly Part B premium after plan reduction: $164.50 (estimated)$209.50 standard premium less $45.00 plan reduction.

You must continue to pay your Medicare Part B premium.

In-network medical deductible: None
Combined in/out-of-network medical deductible: None
Out-of-network medical deductible: None
In-network medical maximum: $3,250.00
Combined in/out-of-network medical maximum: $3,250.00
Out-of-network medical maximum: $3,250.00

Part B premium reduction: $45.00

2027 benefit summary

Doctor visits and medical care

Common medical services and member costs
Service	In-network	Point-of-service	What to know
Primary care doctor	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No
Specialist visit	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Telehealth	$0 Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required Yes Referral required No
Emergency care	$75.00 copay	Not summarized. Check coverage with the plan.
Urgent care	$0	Not summarized. Check coverage with the plan.
Home health	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Dialysis	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Part B chemotherapy and radiation drugs	0% to 20% coinsurance Deductible applies No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes
Other Part B drugs	$0.00 to $7.00 copay; 0% to 20% coinsurance Deductible applies No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes
Kidney disease education services	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Medicare-covered chiropractic	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Medicare-covered foot care	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Other health professionals	$0.00 to $10.00 copay Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
Care	Your share of the cost	What to know
Inpatient hospital stay	$0.00 copay per stay	Approval required Yes Referral required No Benefit period Per Admission or Per Stay
Inpatient hospital stayCost option 2	$50.00 copay per stay	Approval required Yes Referral required No Benefit period Per Admission or Per Stay
Inpatient mental health care	$50.00 copay per stay	Approval required Yes Referral required No Benefit period Per Admission or Per Stay

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
Service	In-network	Point-of-service	What to know
Outpatient hospital care	$25.00 copay Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No
Hospital observation services	$0.00 to $50.00 copay Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No
Ambulatory surgical center	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Outpatient blood	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
Service	In-network	Point-of-service	What to know
Diagnostic procedures and tests	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Laboratory services	0% to 20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Diagnostic radiology (CT, MRI)	$0.00 to $40.00 copay Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Therapeutic radiology	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
X-rays	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No

Mental health and substance use treatment

Mental health and substance use treatment and member costs
Service	In-network	Point-of-service	What to know
Partial hospitalization	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Intensive outpatient program	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Substance use treatment, individual sessions	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Substance use treatment, group sessions	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Opioid treatment program	10% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Mental health, individual sessions	$0.00 to $5.00 copay Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Mental health, group sessions	$0.00 to $5.00 copay Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Psychiatry, individual sessions	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Psychiatry, group sessions	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No

Therapy and rehabilitation

Therapy and rehabilitation and member costs
Service	In-network	Point-of-service	What to know
Occupational therapy	$4.00 copay Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Physical and speech therapy	$4.00 copay Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Cardiac rehabilitation	$5.00 copay Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required Yes
Intensive cardiac rehabilitation	$5.00 copay Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required Yes
Pulmonary rehabilitation	$5.00 copay Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required Yes
Supervised exercise for peripheral artery disease	$5.00 copay Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required Yes

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
Service	In-network	Point-of-service	What to know
Ground ambulance	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes
Air ambulance	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes
Durable medical equipment	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes
Prosthetic devices	5% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes
Medical supplies	5% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes
Diabetic supplies	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes
Diabetic shoes and inserts	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes
Diabetic monitors	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes

Dental benefits

Dental benefits and member costs
Service	In-network	Point-of-service
Medicare-covered dental	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No
Oral examsAdditional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No
Dental X-raysAdditional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No
Other diagnostic dentalAdditional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No
Dental cleaningAdditional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No
FluorideAdditional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No
Other preventive dentalAdditional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No
Restorative dental careAdditional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No
Root canal treatment (endodontics)Additional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No
Gum treatment (periodontics)Additional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No
Removable dentures (prosthodontics)Additional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No
Dental implantsAdditional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No
Fixed dental restorations (prosthodontics)Additional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No
Oral surgeryAdditional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No
Other dental servicesAdditional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No

Vision benefits

Vision benefits and member costs
Service	In-network	Point-of-service	What to know
Medicare-covered eye exams	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Routine eye examsAdditional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Medicare-covered eyewear	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Contact lensesAdditional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Eyeglasses, lenses and framesAdditional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No

Hearing benefits

Hearing benefits and member costs
Service	In-network	Point-of-service	What to know
Medicare-covered hearing exams	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Routine hearing examsAdditional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Hearing aid fitting and evaluationAdditional plan benefit	$0	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Prescription hearing aids (all types)Additional plan benefit	$0 Service-specific deductible No	20% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No

Extra benefits

Extra benefits and member costs
Service	In-network	What to know
Supplemental acupunctureAdditional plan benefit	$10.00 copay Service-specific deductible No	Approval required Yes Referral required No
Over-the-counter health itemsAdditional plan benefit	$0 Service-specific deductible No
Limited-duration mealsAdditional plan benefit	$0 Service-specific deductible No	Approval required Yes Referral required Yes
Fitness benefitAdditional plan benefit	$0 Service-specific deductible No	Approval required Yes Referral required No

Additional services and network costs

Additional network details

These costs apply to the listed service categories and networks.

Additional medical services: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Medicare-covered preventive servicesMedicare-covered care	Point-of-service	20% coinsurance Deductible applies No	Dollar benefit limit applies No
Glaucoma ScreeningMedicare-covered care	Point-of-service	20% coinsurance Deductible applies No	Dollar benefit limit applies No
Diabetes Self-Management TrainingMedicare-covered care	Point-of-service	20% coinsurance Deductible applies No	Dollar benefit limit applies No
Digital Rectal ExamsMedicare-covered care	Point-of-service	20% coinsurance Deductible applies No	Dollar benefit limit applies No
EKG after a Welcome to Medicare visitMedicare-covered care	Point-of-service	20% coinsurance Deductible applies No	Dollar benefit limit applies No
Medicare Part B insulinMedicare-covered care	Point-of-service	20% coinsurance Deductible applies No	Dollar benefit limit applies No
Routine Chiropractic CareAdditional plan benefit	Point-of-service	20% coinsurance Deductible applies No	Dollar benefit limit applies No
Podiatry Services - Routine Foot CareAdditional plan benefit	Point-of-service	20% coinsurance Deductible applies No	Dollar benefit limit applies No

Allowances and optional benefits

OTC COMBINED PACKAGE

One shared limit covers the listed services, not a separate allowance for each service.

Services sharing this allowance: Over-the-counter health items; Fitness Benefit; Home and Bathroom Safety Devices and Modifications
How benefits are provided: Catalogue Purchase
Advance choice of benefits required: No
Shared benefit limit: $40.00
How often this limit applies: Every three months
Shared limit on visits or trips: No

Benefits for qualifying members

DEBIT CARD

The plan must confirm eligibility, including any qualifying condition.

Qualifying conditions: Chronic alcohol use disorder and other substance use disorders (SUDs); Autoimmune disorders; Cancer; Cardiovascular disorders; Chronic heart failure; Dementia; Diabetes mellitus; Overweight, obesity, and metabolic syndrome; Chronic gastrointestinal disease; Chronic kidney disease (CKD); Severe hematologic disorders; HIV/AIDS; Chronic lung disorders; Chronic and disabling mental health conditions; Neurologic disorders; Stroke; Post-organ transplantation; Immunodeficiency and Immunosuppressive disorders; Conditions associated with cognitive impairment; Conditions with functional challenges; Chronic conditions that impair vision, hearing (deafness), taste, touch, and smell; Conditions that require continued therapy services in order for individuals to maintain or retain functioning; Other 1; Other 2; Other 3; Other 4
Qualifying conditions: Chronic Hypertension
Qualifying conditions: Pre-diabetes: Fasting blood glucose: 100-125 mg/dl or Hgb A1C:5.7-6.4%
Qualifying conditions: Osteoporosis
Qualifying conditions: Chronic Back Pain
Covered package services cost $0 until the package limit is reached: No
Benefits that apply to reduced cost sharing: Supplemental benefits; Medicare-covered benefits
Medicare benefits that apply to reduced cost sharing: Inpatient Hospital-Acute; Inpatient Hospital Psychiatric; Cardiac Rehabilitation Services; Intensive Cardiac Rehabilitation Services; Pulmonary Rehabilitation Services; Supervised exercise for peripheral artery disease; Emergency Services; Occupational Therapy Services; Individual Sessions for Mental Health Specialty Services; Group Sessions for Mental Health Specialty Services; Other Health Care Professional; Physical Therapy and Speech-Language Pathology Services; Opioid Treatment Program Services; Lab Services; Diagnostic Radiological Services; Outpatient hospital care; Hospital observation services; Prosthetic Devices; Medical Supplies; Dialysis Services; Medicare Part B insulin; Medicare Part B Chemotherapy/Radiation Drugs; Other Medicare Part B Drugs
Non-Medicare benefits that apply to reduced cost sharing: Additional Days for Inpatient Hospital-Acute; Acupuncture Treatments
Applies to out-of-network or point-of-service care: No
Some package benefits are exempt from the deductible: No
Do you offer reduced Coinsurance?: Yes
Types of benefits that apply to the coinsurance cost sharing: Medicare-covered benefits
Medicare-covered benefits that will receive reduced coinsurance: Opioid Treatment Program Services; Lab Services; Prosthetic Devices; Medical Supplies; Dialysis Services; Medicare Part B Chemotherapy/Radiation Drugs; Other Medicare Part B Drugs
Minimum Coinsurance Percentage for Opioid Treatment Program Services: 0%
Maximum Coinsurance Percentage for Opioid Treatment Program Services: 0%
Minimum Coinsurance Percentage for Lab Services: 0%
Maximum Coinsurance Percentage for Lab Services: 0%
Minimum Coinsurance Percentage for Prosthetic Devices: 0%
Maximum Coinsurance Percentage for Prosthetic Devices: 0%
Minimum Coinsurance Percentage for Medical Supplies: 0%
Maximum Coinsurance Percentage for Medical Supplies: 0%
Minimum Coinsurance Percentage for Dialysis Services: 0%
Maximum Coinsurance Percentage for Dialysis Services: 0%
Minimum Coinsurance Percentage for Medicare Part B Chemotherapy/Radiation Drugs: 0%
Maximum Coinsurance Percentage for Medicare Part B Chemotherapy/Radiation Drugs: 0%
Minimum Coinsurance Percentage for Other Medicare Part B Drugs: 0%
Maximum Coinsurance Percentage for Other Medicare Part B Drugs: 0%
Service-specific deductible: No
Reduced Copayment?: Yes
Types of benefits that apply to the copayment cost sharing: Supplemental benefits; Medicare-covered benefits
Medicare-covered benefits that will receive reduced Copayment: Cardiac Rehabilitation Services; Intensive Cardiac Rehabilitation Services; Pulmonary Rehabilitation Services; Supervised exercise for peripheral artery disease; Emergency Services; Occupational Therapy Services; Individual Sessions for Mental Health Specialty Services; Group Sessions for Mental Health Specialty Services; Other Health Care Professional; Physical Therapy and Speech-Language Pathology Services; Diagnostic Radiological Services; Outpatient hospital care; Hospital observation services; Medicare Part B insulin; Other Medicare Part B Drugs
Supplemental benefits that will receive reduced Copayment: Acupuncture Treatments
Minimum Copayment for Cardiac Rehabilitation Services: $0.00
Maximum Copayment for Cardiac Rehabilitation Services: $0.00
Minimum Copayment for Intensive Cardiac Rehabilitation Services: $0.00
Maximum Copayment for Intensive Cardiac Rehabilitation Services: $0.00
Minimum Copayment for Pulmonary Rehabilitation Services: $0.00
Maximum Copayment for Pulmonary Rehabilitation Services: $0.00
Minimum Copayment for SET for PAD Services: $0.00
Maximum Copayment for SET for PAD Services: $0.00
Minimum Copayment for Emergency Services: $0.00
Maximum Copayment for Emergency Services: $0.00
Minimum Copayment for Occupational Therapy Services: $0.00
Maximum Copayment for Occupational Therapy Services: $0.00
Minimum Copayment for Individual Sessions for Mental Health Specialty Services: $0.00
Maximum Copayment for Individual Sessions for Mental Health Specialty Services: $0.00
Minimum Copayment for Group Sessions for Mental Health Specialty Services: $0.00
Maximum Copayment for Group Sessions for Mental Health Specialty Services: $0.00
Minimum Copayment for Other Health Care Professional: $0.00
Maximum Copayment for Other Health Care Professional: $0.00
Minimum Copayment for Physical Therapy and Speech-Language Pathology Services: $0.00
Maximum Copayment for Physical Therapy and Speech-Language Pathology Services: $0.00
Minimum Copayment for Diagnostic Radiological Services: $0.00
Maximum Copayment for Diagnostic Radiological Services: $0.00
Minimum Copayment for Outpatient Hospital Services: $0.00
Maximum Copayment for Outpatient Hospital Services: $0.00
Minimum Copayment for Observation Services: $0.00
Maximum Copayment for Observation Services: $0.00
Minimum Copayment for Insulin 15-1: $0.00
Maximum Copayment for Insulin 15-1: $0.00
Minimum Copayment for Other Medicare Part B Drugs: $0.00
Maximum Copayment for Other Medicare Part B Drugs: $0.00
Minimum Copayment for Acupuncture: $0.00
Maximum Copayment for Acupuncture: $0.00
Package limit: $42.00
How benefits are provided: Debit Card

Full package terms are not summarized here.

SSBCI Coverage

The plan must confirm eligibility, including any qualifying condition.

Qualifying conditions: Chronic alcohol use disorder and other substance use disorders (SUDs); Autoimmune disorders; Cancer; Cardiovascular disorders; Chronic heart failure; Dementia; Diabetes mellitus; Overweight, obesity, and metabolic syndrome; Chronic gastrointestinal disease; Chronic kidney disease (CKD); Severe hematologic disorders; HIV/AIDS; Chronic lung disorders; Chronic and disabling mental health conditions; Neurologic disorders; Stroke; Post-organ transplantation; Immunodeficiency and Immunosuppressive disorders; Conditions associated with cognitive impairment; Conditions with functional challenges; Chronic conditions that impair vision, hearing (deafness), taste, touch, and smell; Conditions that require continued therapy services in order for individuals to maintain or retain functioning; Other 1; Other 2; Other 3; Other 4
Qualifying conditions: Chronic Hypertension
Qualifying conditions: Pre-diabetes: Fasting blood glucose: 100-125 mg/dl or Hgb A1C:5.7-6.4%
Qualifying conditions: Osteoporosis
Qualifying conditions: Chronic Back Pain
Included services: Over-the-counter health items; Food and produce; Additional meal benefits; Pest control; Transportation for non-medical needs; Indoor Air Quality Equipment and Services; Social support benefit; Support for daily living; Other 1 Non-Primarily Health Related Benefit; Other 3 Non-Primarily Health Related Benefit; Fitness Benefit; Home and Bathroom Safety Devices and Modifications; Oral Exams; Dental X-Rays; Other Diagnostic Dental Services; Restorative dental care; Root canal treatment (endodontics); Gum treatment (periodontics); Removable dentures (prosthodontics); Implant Services; Fixed dental restorations (prosthodontics); Oral and Maxillofacial Surgery; Adjunctive General Services; Contact Lenses; Eyeglasses (lenses and frames); Upgrades; Hearing aid fitting and evaluation; Prescription Hearing Aids (all types)
Applies to out-of-network or point-of-service care: No
Some package benefits are exempt from the deductible: No
Package limit: $42.00
How often this limit applies: Every month
How benefits are provided: Debit Card
Services sharing the package limit: Over-the-counter health items; Food and produce; Additional meal benefits; Pest control; Transportation for non-medical needs; Indoor Air Quality Equipment and Services; Social support benefit; Support for daily living; Other 1 Non-Primarily Health Related Benefit; Other 3 Non-Primarily Health Related Benefit; Fitness Benefit; Home and Bathroom Safety Devices and Modifications; Oral Exams; Dental X-Rays; Other Diagnostic Dental Services; Restorative dental care; Root canal treatment (endodontics); Gum treatment (periodontics); Removable dentures (prosthodontics); Implant Services; Fixed dental restorations (prosthodontics); Oral and Maxillofacial Surgery; Adjunctive General Services; Contact Lenses; Eyeglasses (lenses and frames); Upgrades; Hearing aid fitting and evaluation; Prescription Hearing Aids (all types)

Full package terms are not summarized here.

Prescription drug coverage

Costs shown are for initial coverage.

Standard retail costs

Standard retail: initial-coverage cost per prescription fill
Drug tier	30 days	90 days
Tier 1Preferred Generic	$0.00	$0.00
Tier 2Generic	$0.00	$0.00
Tier 3Preferred Brand	$5.00	$10.00
Tier 4Non-Preferred Drug	$7.00	$14.00
Tier 5Specialty Tier	33%	Not listed
Tier 6Select Care Drugs	$0.00	$0.00

Mail-order and other pharmacies

Out-of-network pricing: You pay the standard retail copay or coinsurance, plus any difference between the pharmacy’s billed charge and the amount the plan allows at a standard retail pharmacy.

Standard mail order costs

Standard mail order: initial-coverage cost per prescription fill
Drug tier	90 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	$0.00
Tier 3Preferred Brand	$10.00
Tier 4Non-Preferred Drug	$14.00
Tier 6Select Care Drugs	$0.00

Long-term care pharmacy costs

Long-term care pharmacy: initial-coverage cost per prescription fill
Drug tier	31 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	$0.00
Tier 3Preferred Brand	$5.00
Tier 4Non-Preferred Drug	$7.00
Tier 5Specialty Tier	33%
Tier 6Select Care Drugs	$0.00

Out-of-network pharmacy costs

Out-of-network pharmacy: initial-coverage cost per prescription fill
Drug tier	30 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	$0.00
Tier 3Preferred Brand	$5.00
Tier 4Non-Preferred Drug	$7.00
Tier 5Specialty Tier	33%
Tier 6Select Care Drugs	$0.00

Drug coverage rules and exceptions

Tier 1: Preferred Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: Yes

Tier 2: Generic

Drugs included in this tier: Both Part D and Excluded Drugs
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: Yes

Tier 3: Preferred Brand

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: Yes

Tier 4: Non-Preferred Drug

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: Yes

Tier 5: Specialty Tier

Drugs included in this tier: Part D Drugs Only

Tier 6: Select Care Drugs

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: Yes

Special cost protections apply to covered insulin and recommended adult vaccines.

Where this plan is offered

CMS lists this plan in 1 state or territory. Availability can vary by county and ZIP code.

View all locations 78 county listings across 1 state or territory