Back to results
Medicare Advantage · HMO
UCLA Health Medicare Advantage Plan
Plan year 2026

UCLA Health Medicare Advantage Principal Plan H4647-001 (HMO)

Monthly premium
$0
+ your Part B premium
Max out-of-pocket
$2,499
in-network annual cap
Primary care
$0
per visit copay
Specialist
$0
per visit

Your costs at a glanceIn-network, for the 2026 plan year

Rx deductible
$250
Inpatient hospital
$200
per stay
no limit on covered hospital days
Inpatient mental health
$200
per stay
Outpatient surgery
$100
Emergency room
$150
Urgent care
$15

What's included, and what it's actually worth5 benefits included. Tap any card for the detail

Hearing

$295–$1,495copay per hearing aid
Details$295–$1,495 copay per hearing aid
This is a supplemental benefit with plan-specific limits. See plan documents for details.

OTC allowance

$60/quarter OTC allowance
Prepaid card$60/quarter OTC allowance

Vision

$150/yr eyewear allowance
Eyewear allowance$150/yr eyewear allowance
This is a supplemental benefit with plan-specific limits. See plan documents for details.
See more details about this plan
Doctor Visits: PCP$0 copay
In-network$0 copay per visit
Doctor Visits: Specialist$0 copay
In-network$0 copay per visit
Inpatient Hospital$200 per stay
In-network$200 per stay
Benefit limitNone — additional covered days are unlimited
Outpatient Surgery$100 copay
In-network$100 copay per procedure
Mental Health$200 per stay
Inpatient psychiatric$200 per stay
Transportation12 one-way trips/year
Trips per year12 one-way trips/year
MealsMeal benefit

Your coverageCheck your coverageFrom the doctors and prescriptions you added

Your plan's drug tiers30-day retail · after any applicable deductible

Tier 1
$0
Preferred Generic
Tier 2
$0
Generic
Tier 3
$47
Preferred Brand· after deductible
Tier 4
45%
Non-Pref Brand· after deductible
Tier 5
30%
Specialty· after deductible

Our take

Where this plan shines

This plan has a $0 monthly premium.
This plan’s out-of-pocket maximum ($2,499) is among the lowest available.
See your primary doctor for $0.
The specialist copay ($0) is among the more affordable options.

Things to know before you enroll

Network restriction — you’ll need to use in-network providers except in emergencies.
Limited coverage while traveling outside the plan’s service area.
Questions? Talk to a licensed agent at1-866-764-3312 (TTY: 711)

Plan documents

Summary of Benefits
No online copy available — call the plan at (833)627-8252 to request the Summary of Benefits
Check Your Doctors
See if your doctors accept this plan
Documentos en español
Llame al (833)627-8252 (TTY: 711) para solicitar documentos en español

Helpful next steps

The Pocket Protector · NPN 21126942 · 1-866-764-3312 (TTY: 711) · thepocketprotector.com

Plan benefits, premiums, and copays may vary by county and plan. You must continue to pay your Medicare Part B premium. Benefits and costs may vary by service area. Contact the plan or CMS for complete details.

We do not offer every plan available in your area. Currently we represent a limited number of organizations which offer a limited number of products in your area. Please contact Medicare.gov, 1-800-MEDICARE (TTY: 1-877-486-2048), or your local State Health Insurance Program (SHIP) to get information on all of your options.

Members may receive a monthly or quarterly allowance in the form of a benefits prepaid card to pay for a wide range of plan-approved items. Unused amounts will expire at the end of the month or quarter.

Out-of-network/non-contracted providers are under no obligation to treat plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you to contact the plan.

Dental, hearing, vision, and other supplemental benefits may have limitations and restrictions. These benefits vary by plan. Please refer to the plan's Evidence of Coverage for details.

The plan formulary, pharmacy network, and/or copays may change at any time. You will receive notice when necessary.

Benefits shown are based on CMS public plan data. Actual benefits vary by county. Not all plans available in all areas. Speak with a licensed agent before enrolling.

  1. The Pocket Protector represents Medicare Advantage HMO, PPO, and PFFS organizations and stand-alone PDP prescription drug plans that have a Medicare contract. Enrollment depends on the plan's contract renewal.
  2. The Pocket Protector is not connected with or endorsed by the United States government or the federal Medicare program.

Privacy Policy

UCLA Health Medicare Advantage Principal Plan (HMO) - UCLA Health Medicare Advantage Plan | The Pocket Protector