Benefits & Cost Sharing Information

For specific information regarding your benefits and cost-sharing as a member of the Upper Peninsula Health Plan (UPHP), refer to the UPHP Evidence of Coverage.  The Evidence of Coverage contains detailed information regarding premiums, copayments, coinsurance, limitations, and more.

Benefits, formulary, pharmacy network, premium, and/or copayments and coinsurance may change Jan. 1 of each year.  Limitations, copayments, and restrictions may apply.  The benefit information provided here is a brief summary, not a complete description of benefits.  Contact UPHP for more information.

Below is a list of your out-of-pocket costs:

CostUPHP Advantage (HMO)UPHP Choice (HMO)
Plan Premium

Calendar year 2020: $113

Calendar year 2019: $110

$0
Yearly Deductible Amount$0

Part B: $0

Part D:
Calendar year 2020: $435 (Applies to Tiers 2, 3, 4 and 5)

Calendar year 2019: $415 (Applies to Tiers 3, 4 and 5)

Maximum Out-of-Pocket Limit for Medicare-covered Services$6,700$6,700
Copayments and CoinsuranceSee the benefits chart in Chapter 4 of the UPHP Evidence of Coverage to learn about copayments and coinsurance.See the benefits chart in Chapter 4 of the UPHP Evidence of Coverage to learn about copayments and coinsurance.

Premiums, copayments, coinsurance, and deductibles may vary based on the level of extra help you receive.  Please contact the plan for further details.

If you currently pay a Medicare Part B premium, you must continue to pay it in addition to the costs above.

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Page Last Updated: 10/10/2019