Advantage Care COPD by Ultimate (HMO C-SNP)
Available to residents of Polk County, FL for 2026. Contract H2962, plan 023, segment 0.
- ✉ Email a copy of the plan benefit details
- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Polk County
- Plan website
- Browse the Advantage Care COPD by Ultimate (HMO C-SNP) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | $185.00 a month?You must continue to pay your Medicare Part B premium. |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $2,600.00? |
| Drug deductible | $0.00 |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO C-SNP? |
| Special needs plan | Chronic-condition SNP |
| Contract / plan | H2962-023-0 |
| Offered by | Ultimate Health Plans |
| Parent organization | Ultimate Healthcare Holdings, LLC |
| Formulary drugs | 3,328 |
| Formulary exception tier | 5? |
| Pharmacy search | www.chooseultimate.com |
| Member services | (800)219-7487TTY 711 |
CMS star ratings
- Overall
- 4 out of 5 stars for Overall
- Health plan (Part C)
- 3.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 3.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H2962 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $3 copay(authorization and referral required) |
| Other health care professional | $3 copay(authorization and referral required) |
| Additional telehealth services | Not covered |
| Preventive care | |
| Medicare-covered preventive services | $0 copay(authorization and referral required) |
| Annual physical exam | Not covered |
| Kidney disease education | $0 copay(referral required) |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $0–$150 copay(authorization and referral required) |
| Lab services | $0–$150 copay; 0%–20% coinsurance(authorization and referral required) |
| Diagnostic radiology (e.g. MRI, CT) | $0–$150 copay(authorization and referral required) |
| Therapeutic radiology | 20% coinsurance(authorization and referral required) |
| Outpatient x-rays | $0–$150 copay(authorization and referral required) |
| Emergency and urgent care | |
| Emergency room | $120 copay |
| Urgent care | $10 copay |
| Worldwide emergency coverage | $100 copay · $50,000 plan limit |
| Worldwide urgent care | Not covered |
| Worldwide emergency transportation | Not covered |
| Hospital care | |
| Inpatient hospital stay | $115 per day for days 1–5; $0 per day for days 6–90(authorization and referral required) |
| Outpatient hospital services | $75–$150 copay(authorization and referral required) |
| Outpatient observation | $150 copay |
| Ambulatory surgical center | $25 copay(authorization and referral required) |
| Outpatient blood services | $0 copay(authorization and referral required) |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $150 per day for days 21–38; $0 per day for days 39–100(authorization and referral required) |
| Home health care | $0 copay(authorization and referral required) |
| Kidney dialysis | 20% coinsurance(authorization and referral required) |
| Rehabilitation | |
| Occupational therapy | $3 copay(authorization and referral required) |
| Physical therapy and speech-language therapy | $3 copay(authorization and referral required) |
| Cardiac rehabilitation | $5 copay(authorization required) |
| Pulmonary rehabilitation | $5 copay(authorization required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $115 per day for days 1–5; $0 per day for days 6–90(authorization and referral required) |
| Outpatient mental health, individual session | $3 copay |
| Outpatient mental health, group session | $3 copay |
| Psychiatrist, individual session | $3 copay |
| Psychiatrist, group session | $3 copay |
| Partial hospitalization | $0 copay(authorization and referral required) |
| Intensive outpatient program | $0 copay |
| Outpatient substance use, individual session | $20 copay |
| Outpatient substance use, group session | $10 copay |
| Opioid treatment program | 20% coinsurance(authorization and referral required) |
| Ambulance and transportation | |
| Ground ambulance | $200 copay(authorization required) |
| Air ambulance | 20% coinsurance(authorization required) |
| Transportation to plan-approved locations | $0 copay |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 0%–20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | $0 copay(authorization required) |
| Diabetic therapeutic shoes or inserts | $0 copay(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $3 copay |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | $3 copay(referral required) |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $0 copay |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | $0 copay(limits apply) |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | Not covered |
| Other preventive dental services | Not covered |
| Restorative services (fillings, crowns) | $0 copay(authorization required, limits apply) |
| Endodontics (root canals) | $0 copay(authorization required, limits apply) |
| Periodontics (gum disease) | $0 copay(authorization required, limits apply) |
| Dentures and other removable prosthodontics | $0 copay(authorization required) |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | Not covered |
| Oral and maxillofacial surgery | $0 copay(authorization required, limits apply) |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay(authorization required) |
| Vision? | |
| Eye exam (Medicare-covered) | $0 copay |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| Eyewear plan limit | $400 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | $30–$50 copay(limits apply) |
| Hearing? | |
| Hearing exam (Medicare-covered) | $0 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay(limits apply) |
| Hearing aid plan limit | $1,000 plan limit every year |
| Hearing aids (all types) | $0 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | $35 copay(authorization required) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required) |
| Other Part B drugs | 0%–20% coinsurance(authorization required) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $110 allowance every month |
| Meals after a hospital stay or for a chronic condition | $0 copay |
| Fitness benefit | $0 copay(referral required) |
| Health education | $0 copay(referral required) |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | $0 copay(referral required) |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay(referral required) |
| Home and bathroom safety devices | $0 copay(referral required) |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | $0 copay(referral required) |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $0.00 |
| Tier 3 | $20.00 |
| Tier 4 | 35% |
| Tier 5 | 33% |
| Tier 6 | $10.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $20.00 | $20.00 | n/a | $60.00 | $60.00 | $40.00 |
| Tier 4: Non-Preferred Drug | 35% | 35% | n/a | 35% | 35% | 35% |
| Tier 5: Specialty Tier | 33% | 33% | n/a | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $10.00 | $10.00 | n/a | $30.00 | $30.00 | $20.00 |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 11 other FL counties
Benefits in plain text
Advantage Care COPD by Ultimate (HMO C-SNP) (H2962-023-0) is a 2026 HMO C-SNP Medicare Advantage plan offered by Ultimate Health Plans, available to residents of Polk County, FL.
The monthly premium is $0.00 (Part C and Part D together).
The plan reduces the member's Medicare Part B premium by $185.00 a month (a "giveback"); the Part B premium itself must still be paid.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $2,600.00.
The drug deductible is $0.00.
It is a special needs plan (Chronic-condition SNP).
The plan's formulary lists 3,328 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $0.00; tier 3: $20.00; tier 4: 35%; tier 5: 33%; tier 6: $10.00.
CMS gives the plan's contract (H2962) an overall rating of 4 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.