UCLA Health Medicare Advantage Principal Plan (HMO) Medicare Advantage Plan H4647-001 • 2026 • Los Angeles County, CA

UCLA Health Medicare Advantage Principal Plan Overview

Coverage Overview for UCLA Health Medicare Advantage Principal Plan

This Medicare Advantage Prescription Drug (MAPD) HMO plan includes hospital, medical, and prescription drug coverage under Medicare Parts A and B. The monthly premium is $0.00, and services are generally covered when received from in-network providers, except in emergency situations. The annual Part D deductible is $250.00.

Primary care visits have a $0 copay, specialist visits come with a $0 copay, urgent care services carry a $15 copay, and ambulance transportation is $200 copay. These costs apply toward the annual maximum out-of-pocket (MOOP) limit of $2499.00. After this limit is reached, in-network services are fully covered.

This plan is listed by CMS under Plan ID H4647-001. A summary of cost sharing is provided below.

Out-of-Pocket Costs

UCLA Health Medicare Advantage Principal Plan includes cost-sharing, which refers to out-of-pocket expenses for covered healthcare services. The table below outlines the most common in-network out-of-pocket costs associated with plan H4647-001.

Certain preventive services are covered 100% by UCLA Health Medicare Advantage Principal Plan as a Part B benefit.

Prescription Drug Coverage

UCLA Health Medicare Advantage Principal Plan includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.

This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.

Prescription Drug Plan Premium

The Part D prescription drug plan premium is included in the overall Medicare Special Needs Plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.

For more details, visit the Social Security Extra Help program .

Prescription Drug Plan Deductible

This plan has a $250.00 annual Part D deductible. You'll pay this deductible at the pharmacy before UCLA Health Medicare Advantage Plan starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, UCLA Health Medicare Advantage Principal Plan may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

CMS 5-Star Ratings

CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.