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VIVA Medicare Prime (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for VIVA Medicare Prime (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on VIVA Medicare Prime (HMO) in 2025, please refer to our full plan details page.
VIVA Medicare Prime (HMO) is a HMO plan offered by Triton Health Systems, L.L.C. available for enrollment in 2025 to people living in Northwest, Central and South Alabama. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that VIVA Medicare Prime (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about VIVA Medicare Prime (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For VIVA Medicare Prime (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $53.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $200.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $7500.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The VIVA Medicare Prime (HMO) plan has a $200 deductible for prescription drugs. In the initial coverage phase, after you meet your deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For example, for a standard pharmacy, you'll pay a $12 copay for preferred generic drugs, and a 41% coinsurance for preferred brand drugs. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The VIVA Medicare Prime (HMO) plan offers coverage for a wide range of services. Inpatient hospital stays have a $325 copay for days 1-6, with no copay for days 7-90. Outpatient services, including primary care and specialist visits, have varying copays, with mental health services costing $25 per session. This plan also includes benefits for hearing, vision, and dental care. Hearing exams are covered with no copay, and routine eye exams have a copay between $0 and $25, while dental services have a maximum annual benefit of $1100. Additional benefits include home health services with no copay, emergency services with a $110 copay, and skilled nursing facility stays with no copay for days 1-20 and 50-100.
Inpatient Hospital See details
Inpatient Hospital services, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with a copay of $325 for days 1-6, and no copay for days 7-90. Additional days for Inpatient Hospital-Acute are covered with no copay, and Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered. Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
Outpatient Services, including Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, Outpatient Substance Abuse Services, and Outpatient Blood Services are covered. Outpatient Hospital Services have a copay between $0 and $325, Observation Services have a $325 copay, and both Individual and Group Sessions for Outpatient Substance Abuse have a $25 copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the VIVA Medicare Prime (HMO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by VIVA Medicare Prime (HMO), but require prior authorization. Medicare-covered ground and air ambulance services have a $300 copay, while transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by VIVA Medicare Prime (HMO) with a $110 copay, and no coinsurance. Urgently Needed Services have a copay between $0 and $40, and no coinsurance. Worldwide Emergency Coverage has a $110 copay and no coinsurance, but Worldwide Urgent Coverage and Worldwide Emergency Transportation are not covered.
Primary Care See details
The VIVA Medicare Prime (HMO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $25 copay, physician specialist services with a copay between $0 and $25, and mental health specialty services with a $25 copay for individual and group sessions. Additionally, the plan covers other health care professional services, psychiatric services, physical therapy and speech-language pathology services with a $25 copay, additional telehealth benefits with a copay between $0 and $25, and opioid treatment program services with a $25 copay. However, routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The VIVA Medicare Prime (HMO) plan covers preventive services, including annual physical exams, with no copay. Additional preventive services are partially covered, but health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and others are not covered. The plan also covers a fitness benefit, remote access technologies, kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following the welcome visit.
Hearing Services See details
Hearing Services include hearing exams with no copay, Routine Hearing Exams with a copay between $0 and $25, and Fitting/Evaluation for Hearing Aid with a copay between $0 and $25. Prescription Hearing Aids (all types) have a copay between $500 and $1975, while OTC Hearing Aids have a copay between $750 and $2850; however, Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear are not covered.
Vision Services See details
The VIVA Medicare Prime (HMO) plan covers vision services, including routine eye exams with a copay between $0 and $25, and eyewear with a combined maximum benefit of $150 every year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
The VIVA Medicare Prime (HMO) plan covers a range of dental services, with a maximum annual benefit of $1100. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, and oral and maxillofacial surgery are covered, while orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered with prior authorization. Insulin has a $35 copay and 0-20% coinsurance, while chemotherapy/radiation drugs and other Medicare Part B drugs have 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the VIVA Medicare Prime (HMO) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits are covered under the VIVA Medicare Prime (HMO) plan, with Durable Medical Equipment (DME) subject to a 20% coinsurance and Diabetic Therapeutic Shoes/Inserts subject to a coinsurance between 20%, while Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered. Prosthetics/Medical Supplies have a coinsurance, and Medical Supplies are covered with a 0% to 20% coinsurance.
Diagnostic and Radiological Services See details
The VIVA Medicare Prime (HMO) plan covers diagnostic and radiological services, but lab services are not covered. Diagnostic Procedures/Tests have a copay between $0 and $50, and Diagnostic Radiological Services have a copay up to $175, while Therapeutic Radiological Services have a copay of $60, and Outpatient X-Ray Services have a $10 copay.
Home Health Services See details
Home Health Services are covered by VIVA Medicare Prime (HMO) with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by VIVA Medicare Prime (HMO), but Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. The copay information is available in the plan details.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the VIVA Medicare Prime (HMO) plan, with prior authorization required. You will have no copay for days 1-20 and days 50-100, but a $196 copay for days 21-49.
Other Services See details
The VIVA Medicare Prime (HMO) plan does not cover acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, or Self-Directed Personal Assistance Services. Over-the-counter items are covered with a maximum benefit of $45.00 every three months, and Other 1 includes an Annual Wellness Visit Enhancement.
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