Plan ID: H2161-002

What You Need to Know:

  • Upper Peninsula Health Plan Advantage (HMO-POS) is a Medicare Advantage Health Maintenance Organization Local HMO plan.
  • It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
  • It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
  • The plan's monthly premium is $114, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is .
  • The plan includes an out-of-pocket maximum of $7,550 per year (in-network).
  • Upper Peninsula Health Plan Advantage (HMO-POS) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is .
  • This plan's Part D Initial Coverage Limit is $40.

$114

Monthly Premium

Medicare Plan Features
Monthly Premium: $114.00
Part C Premium: $73.70
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$114.00 $73.70 $40.30 $0 $40.30 $0 0.0
Gap Coverage: No
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local HMO
Similar Plan: H2161-003
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: No additional gap coverage, only the Donut Hole Discount
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $7,550
Annual Deductible: NULL
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Keweenaw, Michigan: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
less than 10 members Insufficient data to rate this plan. Insufficient data to rate this plan. 3 out of 5 Stars.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 3,763 drugs
Number of Members Enrolled in this Plan in Keweenaw, Michigan: NULL
Number of Drugs Per Tier: NULL
Preferred Pharmacy Cost Sharing During Initial Coverage Phase: NULL
Special Needs Plan SNP Eligibility Requirement: NULL
Monthly Premium Split as Follows:
Part C Premium Part D Base Premium Part D Supplemental Premium Total Premium
$73.70 $40.30 $0.00 $114.00
Monthly Premium with Extra Help Low Income Subsidy:
LIS100 Subsidy Total Monthly Premium with LIS Parts CD LIS25 Subsidy Monthly PartD Premium with LIS LIS25 Subsidy Total Monthly Premium with LIS Parts CD LIS50 Monthly PartD Premium with LIS LIS50 Subsidy Total Monthly Premium with LIS Parts CD LIS75 Monthly PartD Premium with LIS LIS75 Subsidy Total Monthly Premium with LIS Parts CD
$83.90 $32.80 $106.50 $25.30 $99.00 $17.70 $91.40
Formulary Drug Details:
Tier 1 # of Drugs per Tier Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 2 # of Drugs per Tier Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 3 # of Drugs per Tier Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 4 # of Drugs per Tier Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 5 # of Drugs per Tier Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase)
222 $0.00 1455 $10.00 254 $42.00 875 $95.00 957 33%

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HumanaChoice R3887-001 (Regional PPO) (2023)Regional PPO *$5,500$-
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Humana Gold Choice H8145-121 (PFFS) (2023)PFFS *$-$-
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Upper Peninsula Health Plan Choice (HMO) (2023)Local HMO$7,550$285
Insufficient data to rate this plan.
Medicare Plus Blue PPO Assure (PPO) (2023)Local PPO$3,425$0
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Medicare Plus Blue PPO Signature (PPO) (2023)Local PPO$4,700$0
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HumanaChoice R3887-002 (Regional PPO) (2023)Regional PPO$5,300$380
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Medicare Plus Blue PPO Essential (PPO) (2023)Local PPO$6,000$100
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Medicare Advantage Plans by Upper Peninsula Health Plan
Upper Peninsula Health Plan Choice (HMO) (2023)Local HMO$7,550$285
Insufficient data to rate this plan.

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