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UCLA Health Medicare Advantage Principal Plan (HMO)

H4647 - 001 - 0
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UCLA Health Medicare Advantage Principal Plan (HMO) is a Medicare Advantage Plan by UCLA Health Medicare Advantage Plan.

This page features plan details for 2025 UCLA Health Medicare Advantage Principal Plan (HMO) H4647 – 001 – 0 available in Los Angeles County.

Locations

UCLA Health Medicare Advantage Principal Plan (HMO) is offered in the following locations.

California
Los Angeles County, California

Click to see more locations

Plan Overview

UCLA Health Medicare Advantage Principal Plan (HMO) offers the following coverage and cost-sharing.

Insurer:UCLA Health Medicare Advantage Plan
Health Plan Deductible:$0
MOOP:$2,499 In-network
Drugs Covered:Yes

Ready to sign up for UCLA Health Medicare Advantage Principal Plan (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

UCLA Health Medicare Advantage Principal Plan (HMO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $0.00 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

UCLA Health Medicare Advantage Principal Plan (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS 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 $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, 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. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

UCLA Health Medicare Advantage Principal Plan (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
  • Fluoride Treatment
    • In-Network: No Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – No Copay
  • Other Diagnostic Dental Services
    • In-Network: No Coins – No Copay
  • Other Preventive Dental Services
    • In-Network: No Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Lab services
    • $0 copay (Authorization Required, Referral Required)
  • Diagnostic radiology services (e.g., MRI)
    • $0-50 copay (Authorization Required, Referral Required)
  • Outpatient x-rays
    • $0 copay (Authorization Required, Referral Required)
  • Diagnostic tests and procedures
    • $0 copay (Authorization Required, Referral Required)

Doctor visits

  • Specialist
    • $0 copay (Authorization Required, Referral Required)
  • Primary
    • $0 copay

Emergency care/Urgent care

  • Emergency
    • $140 copay per visit (always covered)
  • Urgent care
    • $15 copay per visit (always covered)

Foot care (podiatry services)

  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • $0 copay (Authorization Required, Referral Required)

Ground ambulance

    • $200 copay

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • $0 copay (Limits Apply, Authorization Required, Referral Required)
  • Hearing aids
    • $295-1,495 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • $0 copay (Authorization Required, Referral Required)
  • Hearing aids OTC
    • Not covered

Inpatient hospital coverage

    • $200 per stay
      $200 per day for days 91 and beyond (Authorization Required, Referral Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $2,499 In-network

Medical equipment/supplies

  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • 20-50% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • 0-20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • $0 copay (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • 0-20% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit with a psychiatrist
    • $15 copay (Authorization Required, Referral Required)
  • Outpatient group therapy visit
    • $15 copay (Authorization Required, Referral Required)
  • Outpatient individual therapy visit
    • $15 copay (Authorization Required, Referral Required)
  • Inpatient hospital – psychiatric
    • $200 per stay (Authorization Required, Referral Required)
  • Outpatient individual therapy visit with a psychiatrist
    • $15 copay (Authorization Required, Referral Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • $0-100 copay per visit (Authorization Required, Referral Required)

Preventive care

    • $0 copay

Rehabilitation services

  • Occupational therapy visit
    • $0 copay (Authorization Required, Referral Required)
  • Physical therapy and speech and language therapy visit
    • $0 copay (Authorization Required, Referral Required)

Skilled Nursing Facility

    • $0 per day for days 1 through 20
      $100 per day for days 21 through 100 (Authorization Required, Referral Required)

Transportation

    • $0 copay (Limits Apply, Authorization Required, Referral Required)

Vision

  • Eyeglass frames
    • Not covered
  • Eyeglasses (frames and lenses)
    • $0 copay (Limits Apply, Authorization Required)
  • Routine eye exam
    • $0 copay (Limits Apply, Authorization Required, Referral Required)
  • Contact lenses
    • $0 copay (Limits Apply, Authorization Required)
  • Eyeglass lenses
    • Not covered
  • Other
    • Not covered
  • Upgrades
    • Not covered

Wellness programs (e.g., fitness, nursing hotline)

    • Covered (Authorization Required, Referral Required)

Ready to sign up for UCLA Health Medicare Advantage Principal Plan (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on UCLA Health Medicare Advantage Principal Plan (HMO)? See 2025 UCLA Health Medicare Advantage Principal Plan (HMO) at MedicareAdvantageRX.com.

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Get Help Enrolling

Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.

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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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.

All plan-related information on this site is from CMS.gov and Medicare.gov. We only use data released publicly each year. While our goal is always to provide fact-based, accurate information, information is subject to change, and some data may be inaccurate. Contact a plan for a Summary of Benefits.

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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.

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