Presbyterian Dual Plus (HMO D-SNP) Medicare Special Need Plan H3204-013-4 • 2027
- Monthly Premium
- $0.00Plus Part B premium.
- Medical Deductible
- $0.00
- Maximum Out-of-Pocket
- $9850.00In-network
- Part B Giveback
- Not offered
- Prescription Coverage
- Enhanced, $700.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- See List
- Total Enrollment
- 13,070 beneficiaries
Introduction
CMS Plan ID H3204-013-4 identifies Presbyterian Dual Plus, a Medicare Advantage Dual-Eligible Special Needs Plan (D-SNP) offered by Presbyterian Health Plan. Its provider network is a Health Maintenance Organization (HMO), and Medicare Part D prescription drug coverage is included. For 2027, the plan has a $0.00 monthly premium, $0.00 medical deductible, and $9850.00 in-network maximum out-of-pocket. The 2027 Part D prescription drug deductible is $700.00.
Enrollment across the plan's service areas totals 13,070 beneficiaries, according to CMS. Enrollment is limited to beneficiaries who live within the plan's service area: See List.
Eligibility
Presbyterian Dual Plus is a Medicare D-SNP plan for people who qualify for both Medicare and Medicaid.
- Special Needs Plan Type
- Dual-Eligible Special Needs Plan (D-SNP)
- Medicare Requirement
- Medicare Part A and Part B
- Special Needs Requirement
- Must qualify for Medicaid
- Service Area Requirement
- Must live in the plan's service area
- Prescription Drug Coverage
- Medicare Part D prescription drug coverage is included.
Plan Benefits
Presbyterian Dual Plus has cost-sharing, meaning there are out-of-pocket costs when receiving covered healthcare services. The tables below detail the most common in-network out-of-pocket expenses for plan H3204-013-4.
Compare 2027 plan benefits with 2026.
Office Visits
| Covered Service | 2027 | 2026 |
|---|---|---|
| Primary care | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
| Specialist | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
Preventive and Wellness Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Annual wellness exam | Not covered | Not covered |
| Telehealth benefit | In-network: $0 copay | In-network: $0 copay |
| Routine chiropractic | In-network: $0 copay | In-network: $0 copay |
| Fitness benefits | Coming soon | In-network: $0 copay |
| Health education | In-network: $0 copay | In-network: $0 copay |
| Counseling services | In-network: $0 copay | In-network: $0 copay |
| Over-the-counter drug benefits | In-network: $0 copay | In-network: $0 copay |
| Health transportation (non-emergency) | Coming soon | In-network: $0 copay |
Diagnostic, Lab, and Imaging Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diagnostic radiology services | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
| Lab services | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
| Outpatient x-rays | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
| Diagnostic tests and procedures | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
Emergency and Urgent Care Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Emergency room care | $0 copay | $0 copay |
| Worldwide emergency care | Coming soon | Not covered |
| Urgent care | $0 copay | $0 copay |
| Inpatient hospital care | Tier 1 $0 per day for days 1-60 $0 per day for days 61-90 $0 per day for days 91-150 |
Tier 1 $0 per day for days 1-60 $0 per day for days 61-90 $0 per day for days 91-150 |
| Skilled Nursing Facility | Tier 1 $0 per day for days 1-20 $0 per day for days 21-100 |
Tier 1 $0 per day for days 1-20 $209.5 per day for days 21-100 |
| Ground ambulance | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
Mental Health Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Outpatient individual therapy | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
| Outpatient group therapy | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
| Inpatient psychiatric hospital care | Tier 1 $0 per day for days 1-60 $0 per day for days 61-90 $0 per day for days 91-150 |
Tier 1 $0 per day for days 1-60 $0 per day for days 61-90 $0 per day for days 91-150 |
Rehabilitation Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Physical therapy and speech and language therapy | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
| Occupational therapy | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
Medical Equipment and Supplies
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diabetes supplies | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
| Durable medical equipment | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
| Prosthetics | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
Medicare Part B Drugs
| Covered Service | 2027 | 2026 |
|---|---|---|
| Chemotherapy | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
| Other Part B drugs (Medicare-covered) | In-network: $0 copay | In-network: $0 copay Out-of-network: $0 copay |
Dental Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Oral exam | In-network: $0 copay | In-network: $0 copay |
| Dental x-rays | In-network: $0 copay | In-network: $0 copay |
| Cleaning | In-network: $0 copay | In-network: $0 copay |
| Periodontics | In-network: $0 copay | In-network: $0 copay |
| Endodontics | In-network: $0 copay | In-network: $0 copay |
| Restorative services | In-network: $0 copay | In-network: $0 copay |
| Implant services | Not covered | Not covered |
| Orthodontics | Not covered | Not covered |
| Oral/Maxillofacial surgery | In-network: $0 copay | In-network: $0 copay |
Vision Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Routine eye exam | In-network: $0 copay | In-network: $0 copay |
| Contact lenses | In-network: $0 copay | In-network: $0 copay |
| Eyeglass frames only | In-network: $0 copay | In-network: $0 copay |
| Eyeglass lenses only | In-network: $0 copay | In-network: $0 copay |
| Eyeglasses (frames & lenses) | In-network: $0 copay | In-network: $0 copay |
| Upgrades | In-network: $0 copay | In-network: $0 copay |
Hearing Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Hearing exam | In-network: $0 copay | In-network: $0 copay |
| Fitting/evaluation | In-network: $0 copay | In-network: $0 copay |
| Prescription hearing aids | In-network: $0 copay | In-network: $0 copay |
| OTC hearing aids | Not covered | Not covered |
Additional and Special Needs Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Adult day health services | Not covered | Not covered |
| Home-based palliative care | Not covered | Not covered |
| Personal emergency response system | Coming soon | Not covered |
| Weight management programs | Not covered | Not covered |
| Wigs for chemotherapy-related hair loss | Coming soon | Not covered |
| Alternative therapies | Not covered | Not covered |
| Massage therapy | Not covered | Not covered |
| Home/bathroom safety devices | Not covered | Not covered |
Certain preventive services are covered 100% by Presbyterian Dual Plus as a Part B benefit.
Prescription Drug Coverage
Presbyterian Dual Plus 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.
Prescription Drug Plan Premium
The Part D prescription drug plan premium is included in the overall Medicare Advantage 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.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | ($25.20) |
| Supplemental Part D Premium: | $25.20 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | $6.26 |
| Low-Income Premium Subsidy Paid by CMS: | $0.00 |
| Low-Income Subsidy Premium: | $0.00 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $700.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Presbyterian Health Plan starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, Presbyterian Dual Plus may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | $0.00 copay |
| Generic | $6.80 copay | 25% coinsurance |
| Preferred Brand | 25% coinsurance | 25% coinsurance |
| Non-Preferred Drug | 25% coinsurance | 25% coinsurance |
| Specialty Tier | 25% coinsurance | 25% coinsurance |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H3204)
Medicare assigns star ratings to plans based on quality and performance across multiple measures, including customer service, member experience, and health outcomes. Ratings are updated annually by the Centers for Medicare & Medicaid Services (CMS) and are shown on a 1 to 5 star scale, with 5 stars representing the highest quality.
| CMS Measure | Star Rating |
|---|---|
| 2027 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Contact Information for Presbyterian Health Plan
- Website
- Presbyterian Health Plan Plan Page
- Providers
- Presbyterian Health Plan Providers Page
- Formulary
- Presbyterian Health Plan Formulary Page
- Pharmacy
- Presbyterian Health Plan Pharmacy Page
- New Member Health Plan Help
- (800)347-4766
- New Member Health Plan TTY
- (800)659-8331
- New Member Part D Help
- (800)347-4766
- New Member Part D TTY Users
- (800)659-8331
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Plan Availability
Presbyterian Dual Plus (H3204-013-4) is available in the following locations (click to open):
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Presbyterian Health Plan (official source) | http://www.phs.org/Medicare | October 4, 2026 |
| CMS.gov | Dual Eligible Special Needs Plans (D-SNPs) | April 28, 2026 |
| Medicare.gov | Understanding Medicare Advantage Plans | April 28, 2026 |
| NCOA.org | 5 Steps to Choosing the Right Medicare Plan for You | April 28, 2026 |
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