2022 Upper Peninsula Health Plan Choice (HMO)

Upper Peninsula Health Plan Choice (HMO) H2161-003 is a 2022 Medicare Advantage Plan or Part-C by Upper Peninsula Health Plan available to residents in Michigan. This plan includes additional prescription drug (Part-D) coverage. The Upper Peninsula Health Plan Choice (HMO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $6,700 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,700 out-of-pocket. This can be a extremely nice safety net.

Upper Peninsula Health Plan Choice (HMO) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered.

Upper Peninsula Health Plan works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Upper Peninsula Health Plan Choice (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Upper Peninsula Health Plan and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Upper Peninsula Health Plan except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

2022 Upper Peninsula Health Plan Medicare Advantage Plan Costs

Upper Peninsula Health Plan Choice (HMO) Part-C Premium

Upper Peninsula Health Plan charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H2161-003 Part-D Deductible and Premium

Upper Peninsula Health Plan Choice (HMO) has a monthly drug premium of $0.00 and a $285.00 drug deductible. This Upper Peninsula Health Plan plan offers a $0.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Upper Peninsula Health Plan above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Upper Peninsula Health Plan Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Upper Peninsula Health Plan plan does not offer additional coverage through the gap.

H2161-003 Formulary or Drug Coverage

Upper Peninsula Health Plan Choice (HMO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Upper Peninsula Health Plan Choice (HMO) H2161-003 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	NA	$2
Tier 2	NA	$20
Tier 3	NA	$47
Tier 4	NA	$100
Tier 5	NA	28%

*Initial Coverage Phase and 30 day supply

2021 Upper Peninsula Health Plan Choice (HMO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$10-270 copay
Diagnostic tests and procedures	$15 copay
Lab services	$10 copay
Outpatient x-rays	$20 copay

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Doctor Visits

Primary	$15 copay per visit
Specialist	$45 copay per visit

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$50 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$45 copay
Routine foot care	Not covered

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Ground Ambulance

$200 copay

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Hearing

Fitting/evaluation	Not covered
Hearing aids - inner ear	Not covered
Hearing aids - outer ear	Not covered
Hearing aids - over the ear	Not covered
Hearing exam	$45 copay

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Inpatient Hospital Coverage

$300 per day for days 1 through 6 $0 per day for days 7 through 90

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Medical Equipment/Supplies

Diabetes supplies	20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$310 per day for days 1 through 6 $0 per day for days 7 through 90
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit with a psychiatrist	$40 copay

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MOOP

$7,550 In-network

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

$40-235 copay per visit

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Preventive Care

$0 copay

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Preventive Dental

Cleaning	$0 copay
Dental x-ray(s)	$0 copay
Fluoride treatment	$0 copay
Oral exam	$0 copay

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Rehabilitation Services

Occupational therapy visit	$40 copay
Physical therapy and speech and language therapy visit	$40 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $184 per day for days 21 through 100

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Transportation

Not covered

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Vision

Contact lenses	Not covered
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	Not covered
Other	Not covered
Routine eye exam	Not covered
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Upper Peninsula Health Plan Choice (HMO)

(Click county to compare all available Advantage plans)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.