2027 Medicare Advantage plan

PMC Max (HMO-POS): 2027 benefits and costs

Medicare y Mucho Mas (MMM) HMO-POS

CMS plan ID: H4004-056-0 · Plan year: 2027

PMC Max (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
$206.50 (estimated)$209.50 standard premium less $3.00 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
$3.00

2027 benefit summary

Doctor visits and medical care

Common medical services and member costs
ServiceIn-networkPoint-of-serviceWhat to know
Primary care doctor

$0

Service-specific deductible
No

20% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Specialist visit

$0.00 to $3.00 copay

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 $8.00 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

$5.00 copay

Service-specific deductible
No

20% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Approval required
Yes
Referral required
No
Medicare-covered foot care

$0.00 to $5.00 copay

Service-specific deductible
No

20% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Approval required
Yes
Referral required
No
Other health professionals

$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

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.
CareYour share of the costWhat 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
ServiceIn-networkPoint-of-serviceWhat 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
ServiceIn-networkPoint-of-serviceWhat 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 $25.00 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
ServiceIn-networkPoint-of-serviceWhat 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

$5.00 copay

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

$5.00 copay

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

$0.00 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, 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

Therapy and rehabilitation

Therapy and rehabilitation and member costs
ServiceIn-networkPoint-of-serviceWhat 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
ServiceIn-networkPoint-of-serviceWhat 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% to 10% coinsurance

Service-specific deductible
No

20% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Approval required
Yes
Prosthetic devices

$0

Service-specific deductible
No

20% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Approval required
Yes
Medical supplies

$0

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
ServiceIn-networkPoint-of-serviceWhat to know
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
ServiceIn-networkPoint-of-serviceWhat 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
ServiceIn-networkPoint-of-serviceWhat 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
ServiceIn-networkWhat to know
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
ServiceNetworkYour share of the costWhat to know
Medicare-covered preventive servicesMedicare-covered carePoint-of-service

20% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Glaucoma ScreeningMedicare-covered carePoint-of-service

20% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Diabetes Self-Management TrainingMedicare-covered carePoint-of-service

20% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Digital Rectal ExamsMedicare-covered carePoint-of-service

20% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
EKG after a Welcome to Medicare visitMedicare-covered carePoint-of-service

20% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Medicare Part B insulinMedicare-covered carePoint-of-service

20% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Routine Chiropractic CareAdditional plan benefitPoint-of-service

20% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Podiatry Services - Routine Foot CareAdditional plan benefitPoint-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
$75.00
How often this limit applies
Every one month
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; Chiropractic Services; Occupational Therapy Services; Physician Specialist Services; Individual Sessions for Mental Health Specialty Services; Group Sessions for Mental Health Specialty Services; Podiatry Services; Other Health Care Professional; Individual Sessions for Psychiatric Services; Group Sessions for Psychiatric Services; Physical Therapy and Speech-Language Pathology Services; Opioid Treatment Program Services; Lab Services; Diagnostic Radiological Services; Outpatient hospital care; Hospital observation services; Substance use treatment, individual sessions; Substance use treatment, group sessions; Durable Medical Equipment (DME); Dialysis Services; Medicare Part B insulin; Medicare Part B Chemotherapy/Radiation Drugs; Other Medicare Part B Drugs
Does your MA Uniformity Flexibility/SSBCI cost reduction cover all or some Specialists under Physician Specialist Services?
All specialists
Non-Medicare benefits that apply to reduced cost sharing
Additional Days for Inpatient Hospital-Acute; Routine Chiropractic Care; Podiatry Services - Routine Foot Care
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; Durable Medical Equipment (DME); 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 Durable Medical Equipment (DME)
0%
Maximum Coinsurance Percentage for Durable Medical Equipment (DME)
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; Chiropractic Services; Occupational Therapy Services; Physician Specialist Services; Individual Sessions for Mental Health Specialty Services; Group Sessions for Mental Health Specialty Services; Podiatry Services; Other Health Care Professional; Individual Sessions for Psychiatric Services; Group Sessions for Psychiatric Services; Physical Therapy and Speech-Language Pathology Services; Diagnostic Radiological Services; Outpatient hospital care; Hospital observation services; Substance use treatment, individual sessions; Substance use treatment, group sessions; Medicare Part B insulin; Other Medicare Part B Drugs
Supplemental benefits that will receive reduced Copayment
Routine Chiropractic Care; Podiatry Services - Routine Foot Care
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 Chiropractic Services
$0.00
Maximum Copayment for Chiropractic Services
$0.00
Minimum Copayment for Occupational Therapy Services
$0.00
Maximum Copayment for Occupational Therapy Services
$0.00
Minimum Copayment for Physician Specialist Services
$0.00
Maximum Copayment for Physician Specialist 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 Podiatry Services
$0.00
Maximum Copayment for Podiatry Services
$0.00
Minimum Copayment for Other Health Care Professional
$0.00
Maximum Copayment for Other Health Care Professional
$0.00
Minimum Copayment for Individual Sessions for Psychiatric Services
$0.00
Maximum Copayment for Individual Sessions for Psychiatric Services
$0.00
Minimum Copayment for Group Sessions for Psychiatric Services
$0.00
Maximum Copayment for Group Sessions for Psychiatric Services
$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 Individual Sessions for Outpatient Substance Abuse
$0.00
Maximum Copayment for Individual Sessions for Outpatient Substance Abuse
$0.00
Minimum Copayment for Group Sessions for Outpatient Substance Abuse
$0.00
Maximum Copayment for Group Sessions for Outpatient Substance Abuse
$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 Chiropractic Services - Routine Care
$0.00
Maximum Copayment for Chiropractic Services - Routine Care
$0.00
Minimum Copayment for Podiatry Services - Routine Foot Care
$0.00
Maximum Copayment for Podiatry Services - Routine Foot Care
$0.00
Package limit
$70.00
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
$70.00
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 tier30 days90 days
Tier 1Preferred Generic

$0.00

$0.00

Tier 2Generic

$0.00

$0.00

Tier 3Preferred Brand

$6.00

$12.00

Tier 4Non-Preferred Drug

$8.00

$16.00

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 tier90 days
Tier 1Preferred Generic

$0.00

Tier 2Generic

$0.00

Tier 3Preferred Brand

$12.00

Tier 4Non-Preferred Drug

$16.00

Tier 6Select Care Drugs

$0.00

Long-term care pharmacy costs

Long-term care pharmacy: initial-coverage cost per prescription fill
Drug tier31 days
Tier 1Preferred Generic

$0.00

Tier 2Generic

$0.00

Tier 3Preferred Brand

$6.00

Tier 4Non-Preferred Drug

$8.00

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 tier30 days
Tier 1Preferred Generic

$0.00

Tier 2Generic

$0.00

Tier 3Preferred Brand

$6.00

Tier 4Non-Preferred Drug

$8.00

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

Puerto Rico