UCLA Health Medicare Advantage Prestige Plan (HMO)

California Medicare Advantage Plan (2025 Plan)


Monthly Premium

Your Cost
$39
by UCLA Health Medicare Advantage Plan

Additional Coverage

HearingVisionDental

Overall Government Star Rating

(coming soon)

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Plan Name
UCLA Health Medicare Advantage Prestige Plan (HMO)
Insurance Carrier
UCLA Health Medicare Advantage Plan
Plan Type
Medicare Advantage Plan With Part D Prescription Drug Coverage
Network Type
HMO

UCLA Health Medicare Advantage Prestige Plan (HMO) is a Medicare Advantage Plan With Part D Prescription Drug Coverage, which is available in California and offered by the health insurance company UCLA Health Medicare Advantage Plan. This plan’s network type is HMO which determines in-network doctors who accept the health plan and whether a referral is needed.

Monthly Premium
$39
Annual Deductible
$0
Max Out-of-Pocket
$1,499
Primary doctor visit
$0 copay
Specialist visit
$0 copay
ER visit
$75 copay per visit (always covered)
Ambulance
$100 copay

UCLA Health Medicare Advantage Prestige Plan (HMO) has a monthly premium cost of $39 per month, with an annual deductible of $0 and a maximum out of pocket cost sharing of $1,499 In-network. The most common benefit costs which people evaluate when choosing a plan are costs for a primary doctor visit, specialist doctor visit, emergency room visit, and ambulance. These costs are listed in this summary section and a full list of benefit costs for UCLA Health Medicare Advantage Prestige Plan (HMO) are defined below.

Yes
Part D Prescription Drug Coverage
Yes
Dental
Yes
Vision
Yes
Hearing

UCLA Health Medicare Advantage Prestige Plan (HMO) is a Medicare Advantage plan which does include Medicare Part D Prescription Drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. UCLA Health Medicare Advantage Prestige Plan (HMO) includes coverage for hearing, vision, dental.

Medicare Advantage health plans can offer even more additional benefits. UCLA Health Medicare Advantage Prestige Plan (HMO) includes coverage for the following additional benefits:

Other benefits

Fitness benefit
Limited coverage
Over the counter drug benefits
Limited coverage
In-home support services
Limited coverage
Home and bathroom safety devices
Not covered
Meals for short duration
Limited coverage
Annual physical exams
Limited coverage
Telehealth
Limited coverage

Monthly Premium
$39
Health Portion of Premium
$0
Drug Portion of Premium
$39
Health Plan Deductible
$0
Health Plan Max Out-of-Pocket
$1,499 In-network
Nationwide Coverage included
No
Hearing Coverage included
Yes
Vision Coverage included
Yes
Dental Coverage included
Yes

Doctor Services

Primary doctor visit
$0 copay
Specialist visit
$0 copay

Tests, labs, & imaging

Diagnostic tests & procedures
$0 copay
Lab services
$0 copay
Diagnostic radiology services (like MRI)
$0-50 copay
Outpatient x-rays
$0 copay
Emergency care
$75 copay per visit (always covered)
Urgent care
$15 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage
$0 copay per stay
$0 per day for days 91 and beyond
Outpatient hospital coverage
$0 copay

Skilled nursing facility

Skilled nursing facility
$0 per day for days 1 through 20
$75 per day for days 21 through 100

Preventive services

Preventive services
$0 copay

Ambulance

Ground ambulance
$100 copay

Therapy services

Occupational therapy visit
$0 copay
Physical therapy & speech & language therapy visit
$0 copay

Mental health services

Outpatient group therapy with a psychiatrist
$15 copay
Outpatient individual therapy with a psychiatrist
$15 copay
Outpatient group therapy visit
$15 copay
Outpatient individual therapy visit
$15 copay

Opioid treatment services

Opioid treatment services
Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)
20-50% coinsurance per item
Prosthetics (like braces, artificial limbs)
0-20% coinsurance per item
Diabetes supplies
$0 copay

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseCatastrophic coverage phase
Preferred Generic$0.00 copay$0 copay
Generic$0.00 copay$0 copay
Preferred Brand$47.00 copay$0 copay
Non-Preferred Drug45% coinsurance$0 copay
Specialty Tier33% coinsurance$0 copay

Part B Drugs

Chemotherapy drugs
0-20% coinsurance
Other Part B drugs
0-20% coinsurance

Hearing

Hearing exam
$0 copay
Fitting/evaluation
$0 copay
Hearing aids - All types
$195-1,395 copay

Preventive Dental

Oral exam
In-network: $0 copay
Out-of-network: $0 copay
Cleaning
In-network: $0 copay
Out-of-network: $0 copay
Fluoride treatment
In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays
In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Restorative services
In-network: $7-$410 copay
Out-of-network: $7-$410 copay
Endodontics
In-network: $12-$154 copay
Out-of-network: $12-$154 copay
Periodontics
In-network: $0-$130 copay
Out-of-network: $0-$130 copay
Prosthodontics, removable
In-network: $16-$656 copay
Out-of-network: $16-$656 copay
Prosthodontics, fixed
In-network: $42-$412 copay
Out-of-network: $42-$412 copay
Maxillofacial prosthetics
Not covered
Implant services
Not covered
Oral and maxillofacial surgery
In-network: $3-$152 copay
Out-of-network: $3-$152 copay
Orthodontics
Not covered
Adjunctive general services
In-network: $0-$64 copay
Out-of-network: $0-$64 copay

Vision

Routine eye exam
$0 copay
Contact lenses
$0 copay
Eyeglasses (frames & lenses)
$0 copay
Eyeglass frames (only)
Not covered
Eyeglass lenses (only)
Not covered
Upgrades
Not covered

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