Providence Medicare Sycamore + Rx (HMO)
Providence Medicare Advantage Plans · HMO · 2026 coverage
The big numbers
The plan premium is on top of your Part B premium.
- Monthly premium
- $0
- Most you pay in a year for covered care in network
- $400
- Lower than most plans here
- Drug deductible
- $0
- Tied for lowest here
- Medicare star rating
- 4 of 5
In plain English
Compared with the 63 other plans in Orange County that the same person could join.
What stands out
- No monthly premium
- At most $400 a year for covered care, lower than most plans here
- $0 for a 5-day hospital stay, tied for lowest here
- No drug deductible, tied for lowest here
Watch out for
- $150 for the emergency room, tied for highest here
- You need a referral to see a specialist
- Covers only the plan’s own doctors and hospitals, except in an emergency or for urgent care
What a year could cost
Premiums plus the plan’s copays for three example years. Medicines are not included.
- A light year$0$0 in premiums + $0 for care2 checkups and 2 lab tests.
- A busier year$0$0 in premiums + $0 for careTied for lowest here4 checkups, 4 specialist visits, 4 lab tests, 1 X-ray and 1 urgent care visit.
- A hard year$250$0 in premiums + $250 for careLower than most plans here6 checkups, 12 specialist visits, 6 lab tests, 2 scans, an ambulance ride, an ER visit and a 5-day hospital stay.
The visit counts are examples we chose to show how costs add up, not a prediction. Your costs depend on the care you get.
What you pay for care
Your cost each time, at doctors and hospitals in the plan’s network.
- Primary care visit$0
- Specialist visit$0Referral needed
- Urgent care$0
- Emergency room$150Tied for highest hereNot charged if you stay in the hospital within 24 hours
- Hospital stay$0 per stayTied for lowest herePlan approval may be needed
- Lab tests$0Plan approval may be needed
More care: surgery, X-rays, scans, ambulance, nursing home
- Outpatient surgery center$0Plan approval may be needed
- Outpatient hospital care$0
- X-rays$0Plan approval may be needed
- MRI, CT and other scans$0Plan approval may be needed
- Ground ambulance$100Lower than most plans herePlan approval may be needed
- Skilled nursing facility$0 for days 1 to 20, then $100 a day for days 21 to 100Plan approval may be needed
From the costs the plan filed with Medicare for 2026. A range like “$0 to $100” means the cost depends on the service or the place. “Lower than most” compares this plan with the 63 other plans in Orange County that the same person could join. Read the plan’s 2026 booklet (PDF)
What medicines cost
| Drug tier | Preferred pharmacy | Other network pharmacy |
|---|---|---|
| 1Preferred Generic | $0 | $16 |
| 2Generic | $0 | $20 |
| 3Preferred Brand | $40 | $47 |
| 4Non-Preferred Drug | $100 | $100 |
| 5Specialty Tier | 33% of the price | 33% of the price |
For a 1-month supply. Covered insulin costs at most $35 for a month’s supply. Your medicine’s tier is on the plan’s drug list; check it below.
Check my medicines
See if this plan covers each medicine you take in 2026, and what a month costs.
Type the name on the bottle. Add the strength to narrow it down.
Add each medicine once. We’ll show if this plan covers it, what a month costs, and any rules.
Extras
Help Original Medicare doesn’t give you.
- Dental IncludedCleanings and exams: $0. Fillings, crowns and dentures: you pay $0.Cleanings and exams: plan pays up to $350 every six months. Plan pays up to $350 every six months for all dental.
- Vision IncludedYearly eye exam: $0.
- Hearing IncludedHearing test: $0. Hearing aids covered.
- Over-the-counter items Not included
- Fitness IncludedIncludes gym or fitness classes.
- Rides to care Not included
Is my doctor in this plan?
Look up your doctors, then confirm with their office.
Call each doctor’s office and ask:
“Do you take Providence Medicare Sycamore + Rx (HMO), plan number H9047-066, for 2026?”