Presbyterian UltraFlex (HMO-POS) 2025 Plan Details for Sandoval County, New Mexico Residents
Presbyterian UltraFlex (HMO-POS) 2025 Plan Details for Sandoval County, New Mexico Residents
Choosing the right Medicare Advantage plan in Sandoval County is crucial for your healthcare needs in 2025. With Presbyterian UltraFlex (HMO-POS) as one of the options, you can compare it side-by-side with other available plans to find the best fit for you. Whether you prefer enrolling online or seeking advice from a licensed agent, we’ve made the process simple and straightforward.
According to CMS enrollment data (May, 2025), there are approximately 6,562 members enrolled in this plan, 1,136 in Sandoval County.
Presbyterian UltraFlex Overview
| Plan ID H3204-015-0 Overview | |
|---|---|
| Health Plan ID: | H3204-015-0 |
| Medicare Advantage Plan Type: | HMO-POS |
| Plan Year: | 2025 |
| Monthly Premium: | $0.00 Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Annual Out-of-Pocket Maximum: | $5,700.00 (In-Network) |
| Part B Give Back: | $0.00/mo |
| Part D Drug Plan Benefit: | Enhanced, $0.00 deductible |
| Additional Benefits: | Dental, Vision, Hearing |
| Availability: | Sandoval County, NM |
| Insured By: | Presbyterian Health Plan |
Why Consider Presbyterian UltraFlex ?
This Medicare Advantage Prescription Drug (MAPD) HMO-POS plan combines complete coverage with flexible provider access. With a monthly premium of $0.00, Presbyterian UltraFlex includes Medicare Part A and Part B benefits, plus prescription drug coverage to manage ongoing medication needs. The annual Part D deductible is $0.00. You can visit providers both in and out of network — but you’ll generally save more when choosing in-network care.
Primary care visits have a not covered, specialist visits come with a $45 copay, urgent care services carry a $55 copay, and ambulance transportation is $420 copay. These costs apply toward the plan’s maximum out-of-pocket (MOOP) limit of $5,700.00 . After you reach that cap, all in-network services are covered in full through year’s end.
You’ll find this plan listed by CMS as H3204-015-0. A summary of cost sharing appears below. Still have questions? Check the FAQ section for more info.
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Cost-Sharing Overview
With Presbyterian UltraFlex , you'll have cost-sharing expenses, which are the out-of-pocket costs for approved healthcare services. The table below provides a summary of the typical in-network out-of-pocket costs associated with plan H3204-015-0.
Find out the costs for visiting your primary care doctor and specialists, as well as coverage for wellness and preventive programs.
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | Not Covered |
| Specialist: | $45 Copay |
Review the costs for emergency services, urgent care, ambulance services, inpatient hospital stays, and skilled nursing facility care.
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $125 Copay |
| Urgent care: | $55 Copay |
| Ground ambulance: | $420 Copay |
| Inpatient hospital care: | $450.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $210.00 per day for days 21 and beyond |
This section covers Medicare-approved foot care services, including exams and routine foot care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | Not Covered |
| Routine Foot Care: | Not Covered |
Understand the coverage for Medicare-approved chiropractic services and routine chiropractic care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $20 Copay |
| Routine chiropractic: | Not Covered |
This section explains the costs for mental health services, including individual and group therapy, and inpatient care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | Not Covered |
| Outpatient group therapy: | Not Covered |
| Inpatient psychiatric hospital care: | $450.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
See the cost details for rehabilitation services, including physical therapy, speech therapy, and occupational therapy.
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $25 Copay |
| Occupational therapy: | $25 Copay |
Learn about the costs associated with medical equipment and supplies, including diabetes supplies, durable medical equipment, and prosthetics.
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | Not Covered |
| Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
| Prosthetics: | 20% Coinsurance |
This section outlines the costs for diagnostic services, lab tests, x-rays, and other imaging services.
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $350 Copay |
| Lab services: | Not Covered |
| Outpatient x-rays: | $30 Copay |
| Diagnostic tests and procedures: | Not Covered |
Review the cost-sharing details for chemotherapy and other Medicare Part B-covered drugs.
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
This section details the dental services covered under your plan including, Medicare-covered preventive dental, oral exams, x-rays, dental cleanings, and comprehensive dental.
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | $55 Copay |
| Oral exam | |
| Dental x-rays | |
| Cleaning | |
| Periodontics | |
| Endodontics | |
| Restorative Services |
This section outlines the coverage for hearing-related services, including exams, fittings, and hearing aids.
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Covered Limits may apply |
| Hearing exam | Covered Limits may apply |
Learn about the costs for vision-related services, including eye exams, eyeglasses, and contact lenses.
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam (in-network) | $0 to $10 Copay |
| Routine eye exam (in-network) | Covered Limits may apply |
| Eyewear benefits | Eyeglasses: Yes Contact Lenses: Yes Eyeglass Lenses: Yes Eyeglass Frames: Yes Eyewear Upgrades: Yes |
Maximum eyewear benefit: | $90.00 Every three months |
Certain preventive services are covered 100% by Presbyterian UltraFlex as a Part B benefit.
Part D Prescription Drug Costs & Benefits
Presbyterian UltraFlex includes an enhanced benefit Medicare Part D plan (PDP), which offers greater coverage than basic plans. An enhanced benefit plan has a higher actuarial value, meaning it covers a larger percentage of your healthcare costs.
Part D Plan Premium
The Part D prescription drug plan premium is included in your overall Medicare Advantage plan cost. However, additional expenses or subsidies may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help. LIS, provided by Social Security, helps those with limited income and resources to lower or eliminate Part D costs. LIS benefits are not part of Medicare Advantage coverage.
| Basic Part D Premium: | $0.00 |
|---|---|
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | ${part_d_lips_amount} |
| Low-Income Premium Subsidy Paid by CMS: | $0.00 |
| Low-Income Subsidy Premium: | $0.00 |
For more details, visit the Social Security Extra Help program.
Prescription Drug Plan Deductible
This plan has a $0.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Presbyterian Health Plan starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, Presbyterian UltraFlex may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $4.00 | $4.00 |
| Generic | $10.00 | $10.00 |
| Preferred Brand | $45.00 | $45.00 |
| Non-Preferred Drug | 50.00% | 50.00% |
| Specialty Tier | 33.00% | 33.00% |
| *Deductible does not apply. | ||
Understanding CMS Star Ratings
The Centers for Medicare & Medicaid Services (CMS) reviews and rates Medicare Advantage (Part C) and drug plans (Part D) annually, using a 5-star system to measure aspects such as member satisfaction, preventive services, and management of chronic conditions.
Higher star ratings generally indicate better plan performance, which can be a useful factor to consider when deciding on a plan that aligns with your healthcare goals and preferences.
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
If you are new to Medicare or Medicare Advantage plans, the following information will help you understand the enrollment process and restrictions.
Eligibility Requirements for Presbyterian UltraFlex
To qualify for enrollment in Presbyterian UltraFlex , you must:
- Be entitled to Medicare Part A and enrolled in Medicare Part B.
- Live within the plan’s designated service area.
If you fulfill these criteria, you can enroll in Presbyterian UltraFlex and enjoy the extensive healthcare benefits it offers.
Enrollment Periods for Presbyterian UltraFlex
Understanding the right time to enroll in Presbyterian UltraFlex is crucial. Here are the key enrollment periods:
- Initial Enrollment Period (IEP): Your first opportunity to enroll in Medicare starts three months before your 65th birthday and lasts until three months after your birthday month.
- Annual Enrollment Period (AEP): Occurring annually from October 15 to December 7, the AEP allows you to enroll in, switch, or drop a Medicare Advantage plan if you are currently enrolled in a Medicare Advantage plan.
- Medicare Advantage Open Enrollment Period (MA OEP): From January 1 to March 31 each year, the MA OEP gives you the chance to switch Medicare Advantage plans or return to Original Medicare.
- Special Enrollment Periods (SEPs): Certain life changes, like moving or losing other coverage, may make you eligible for a SEP, allowing you to adjust your plan outside the usual periods.
Not sure when to enroll? Call HealthCompare (our trusted enrollment partner) at 1-833-748-3201 (TTY 711) to speak with a licensed insurance agent who can guide you through your options.
How to Enroll in Presbyterian UltraFlex
Joining Presbyterian UltraFlex is straightforward. Here are the steps you can take:
- Online: Use our online enrollment partner's Secure Online Enrollment Form to sign up.
- By Phone: Reach out to HealthCompare (our trusted enrollment partner) at 1-833-748-3201 (TTY 711). A licensed insurance agent will help you with the enrollment process and answer any questions you might have.
- Through Medicare.gov: Enroll directly through the official Medicare website. Visit Medicare.gov, log in or create an account, and follow the steps to join Presbyterian UltraFlex .
- Direct Enrollment: You can also choose to enroll directly with Presbyterian UltraFlex . The contact information can be found below in the "Contact" section.
Make sure you enroll during the appropriate period to activate your coverage as soon as possible.
Here are some of the most frequently asked questions people have about plan ID H3204-015-0:
How much does H3204-015-0 cost per month?
Members pay their Part B premium and the plan's of $0.00 per month to be in this 2025 plan.
What is the annual out-of-pocket maximum on this plan?
For 2025, the maximum you’d spend out-of-pocket in-network is $5,700.00 .
What’s the prescription-drug deductible for 2025?
Yes. The Part D deductible is $0.00. The plan does not have a drug tier without a deductible.
How is this plan rated by Medicare?
For 2025, plan H3204-015-0 has a ★3.0 rating. The best rating is 5 stars.
Is Presbyterian UltraFlex popular?
CMS reports 6,562 members in the latest file.
Contact Presbyterian Health Plan
| Website: | Presbyterian Health Plan Plan Page |
|---|---|
| Providers: | Presbyterian Health Plan Providers Page |
| Formulary: | Presbyterian Health Plan Formulary Page |
| Pharmacy: | Presbyterian Health Plan Pharmacy Page |
| New Member Health Plan Help: | (800)347-4766 |
| New Member Health Plan TTY: | (800)659-8331 |
| New Member Part D Help: | (800)347-4766 |
| New Member Part D TTY Users: | (800)659-8331 |
If you're eligible for Medicare but haven't enrolled or need to verify your enrollment status, visit the Social Security Administration website. For more information about Medicare Advantage, visit medicare.gov.
- Presbyterian Health Plan, http://www.phs.org/Medicare, Last Accessed June 1, 2025
- Medicare.gov, "Compare types of Medicare Advantage Plans", Last Accessed 25 May, 2025
- AARP.org, "The Big Choice: Original Medicare vs. Medicare Advantage", Last Accessed 25 May, 2025
- Medicare.gov, "Compare Original Medicare & Medicare Advantage", Last Accessed 25 May, 2025
- CMS.gov, Landscape Source Files, Last Accessed October 15, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed October 15, 2024
- CMS.gov, Plan Benefits Package, Last Accessed October 15, 2024
- CMS.gov, Monthly Enrollment by Contract/Plan/State/County, Last Accessed June 6, 2025
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