Upper Peninsula Health Plan MI Coordinated Health (HMO D-SNP)
Available to residents of Marquette County, MI for 2026. Contract H3127, plan 001, 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 Marquette County
- Plan website
- Browse the Upper Peninsula Health Plan MI Coordinated Health (HMO D-SNP) formulary
Renewed, service area reduced for 2026. CMS crosswalks 2025’s Upper Peninsula Health Plan MI Health Link (Medicare-Medicaid Plan) (H1977-001-0) into this plan, so its members move here unless they choose otherwise.
Plan details
| Monthly premium (Part C + D) | $8.80 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $8.80? |
| Drug premium in CMS's quarterly plan file | $0.00The CMS Landscape file above lists $8.80 for the drug part; the two CMS files differ for this plan. |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| In-network out-of-pocket maximum | $9,250.00? |
| Drug deductible | $615.00 |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO D-SNP? |
| Special needs plan | Dual-eligible SNP |
| Contract / plan | H3127-001-0 |
| Offered by | Upper Peninsula Health Plan (UPHP) MI Coordinated |
| Parent organization | DLP Marquette Health Plan, LLC |
| Formulary drugs | 3,508 |
| Pharmacy search | www.uphp.com/pharmacy/ |
| Member services | (877)349-9324TTY 711 |
CMS star ratings
- Overall
- —
- Health plan (Part C)
- —
- Drug plan (Part D)
- —
Published per contract — every plan under contract H3127 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | 20% coinsurance |
| Specialist | 20% coinsurance(authorization required) |
| Other health care professional | 20% coinsurance(authorization and referral required) |
| Additional telehealth services | Not covered |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | Not covered |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | 20% coinsurance(authorization and referral required) |
| Lab services | 20% coinsurance(authorization and referral required) |
| Diagnostic radiology (e.g. MRI, CT) | 20% coinsurance |
| Therapeutic radiology | 20% coinsurance |
| Outpatient x-rays | 20% coinsurance |
| Emergency and urgent care | |
| Emergency room | 20% coinsurance |
| Urgent care | 20% coinsurance |
| Worldwide emergency coverage | Not covered |
| Worldwide urgent care | Not covered |
| Worldwide emergency transportation | Not covered |
| Hospital care | |
| Inpatient hospital stay | Original Medicare cost-sharing(authorization required) |
| Outpatient hospital services | 20% coinsurance(authorization required) |
| Outpatient observation | 20% coinsurance(authorization required) |
| Ambulatory surgical center | 20% coinsurance |
| Outpatient blood services | 20% coinsurance |
| Skilled nursing and home health | |
| Skilled nursing facility | Original Medicare cost-sharing(authorization and referral required) |
| Home health care | $0 copay(referral required) |
| Kidney dialysis | 20% coinsurance(referral required) |
| Rehabilitation | |
| Occupational therapy | 20% coinsurance |
| Physical therapy and speech-language therapy | 20% coinsurance |
| Cardiac rehabilitation | 20% coinsurance(referral required) |
| Pulmonary rehabilitation | 20% coinsurance(referral required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | Original Medicare cost-sharing(authorization required) |
| Outpatient mental health, individual session | 20% coinsurance |
| Outpatient mental health, group session | 20% coinsurance |
| Psychiatrist, individual session | 20% coinsurance |
| Psychiatrist, group session | 20% coinsurance |
| Partial hospitalization | 20% coinsurance(authorization required) |
| Intensive outpatient program | 20% coinsurance |
| Outpatient substance use, individual session | 20% coinsurance |
| Outpatient substance use, group session | 20% coinsurance |
| Opioid treatment program | 20% coinsurance |
| Ambulance and transportation | |
| Ground ambulance | 20% coinsurance |
| Air ambulance | 20% coinsurance |
| Transportation to plan-approved locations | Not covered |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | 20% coinsurance(authorization required) |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | 20% coinsurance(authorization required) |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | 20% coinsurance |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | 20% coinsurance |
| Oral exams | Not covered |
| Cleanings | Not covered |
| Fluoride treatment | Not covered |
| Dental x-rays | Not covered |
| Other diagnostic dental services | Not covered |
| Other preventive dental services | Not covered |
| Restorative services (fillings, crowns) | Not covered |
| Endodontics (root canals) | Not covered |
| Periodontics (gum disease) | Not covered |
| Dentures and other removable prosthodontics | Not covered |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | Not covered |
| Oral and maxillofacial surgery | Not covered |
| Orthodontics | Not covered |
| Adjunctive general services | Not covered |
| Vision? | |
| Eye exam (Medicare-covered) | 20% coinsurance |
| Routine eye exam | Not covered |
| Eyewear after cataract surgery (Medicare-covered) | 20% coinsurance(authorization required) |
| Contact lenses | Not covered |
| Eyeglasses (frames and lenses) | Not covered |
| Eyeglass lenses | Not covered |
| Eyeglass frames | Not covered |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | 20% coinsurance(referral required) |
| Routine hearing exam | Not covered |
| Hearing aid fitting and evaluation | Not covered |
| Hearing aids (all types) | Not covered |
| 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 | 0%–20% coinsurance(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 | $42 allowance every month |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | Not covered |
| Health education | Not covered |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | Not covered |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| 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 |
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 | $0.00 | $0.00 | $0.00 | $0.00 |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 11 other MI counties
Benefits in plain text
Upper Peninsula Health Plan MI Coordinated Health (HMO D-SNP) (H3127-001-0) is a 2026 HMO D-SNP Medicare Advantage plan offered by Upper Peninsula Health Plan (UPHP) MI Coordinated, available to residents of Marquette County, MI.
The monthly premium is $8.80 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
Its in-network out-of-pocket maximum is $9,250.00.
The drug deductible is $615.00.
It is a special needs plan (Dual-eligible SNP).
The plan's formulary lists 3,508 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00.
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.