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Astiva Health Premier Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Astiva Health Premier Plan (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Astiva Health Premier Plan (HMO) in 2025, please refer to our full plan details page.
Astiva Health Premier Plan (HMO) is a HMO plan offered by Astiva Health Holdings Incorporated available for enrollment in 2025 to people living in Counties: OC, LA, RIV, SB, SD. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Astiva Health Premier Plan (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 Astiva Health Premier Plan (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 Astiva Health Premier Plan (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $1500.00 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 Astiva Health Premier Plan (HMO) has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, in the initial coverage phase, you will pay no copay for preferred generic drugs and specialty tier drugs at standard and mail order pharmacies. You will pay a $35 copay for standard generic drugs and a $95 copay for preferred brand drugs. Non-preferred drugs have a 33% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Astiva Health Premier Plan (HMO) offers comprehensive coverage, including inpatient and outpatient hospital services, with varying copays depending on the service. The plan offers additional benefits like hearing and vision services, with no copays for routine exams. Dental services are covered with coinsurance or maximum benefits, and the plan also covers home health, skilled nursing, and ambulance services. This plan includes coverage for emergency services, with a copay, and also offers some coverage for medical equipment, and home infusion. The plan also includes additional benefits such as acupuncture, and an over-the-counter (OTC) allowance. However, some services like annual physical exams and certain types of hearing aids are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a $0 copay for days 1-5, a $150 copay for days 6-15, and a $0 copay for days 16-90. Additional days for Inpatient Hospital Psychiatric have a $0 copay for days 91-150. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services, are covered under the Astiva Health Premier Plan (HMO). Outpatient Hospital Services have a $50 copay, and Individual and Group Sessions for Outpatient Substance Abuse have a copay between $15 and $15.
Partial Hospitalization See details
Partial Hospitalization is covered by the Astiva Health Premier Plan (HMO) with a $50 copay, and requires prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Astiva Health Premier Plan (HMO), including ground and air ambulance services. Ground ambulance services have a $50 copay, and air ambulance services have 20% coinsurance, while transportation services to a plan-approved health-related location are not covered, but transportation services to any health-related location are covered up to 48 one-way trips per year.
Emergency Services See details
Emergency Services, including urgently needed services and worldwide emergency services, are covered under the Astiva Health Premier Plan (HMO). Emergency Services have a $75 copay with no coinsurance, and the copay is waived if admitted to the hospital within 48 hours. Worldwide emergency services are covered up to $50,000, while worldwide emergency transportation is not covered.
Primary Care See details
The Astiva Health Premier Plan (HMO) covers primary care physician services, occupational therapy services, physician specialist services, and psychiatric services with a copay. Chiropractic Services are partially covered, and Routine Chiropractic Care and Individual and Group Sessions for Mental Health Specialty Services are not covered. Physical Therapy and Speech-Language Pathology Services have a $15 copay.
Preventive Services See details
The Astiva Health Premier Plan (HMO) covers preventive services, including Medicare-covered services with no copay, as well as additional preventive services that require prior authorization and a doctor referral. Specifically, this plan does not cover annual physical exams, health education, in-home safety assessments, medical nutrition therapy, post discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, counseling services, telemonitoring services, remote access technologies, home and bathroom safety devices, and in-home support services.
Hearing Services See details
Hearing Services are covered by the Astiva Health Premier Plan (HMO), including hearing exams, with no copay. Routine hearing exams are covered for 1 visit every year, and fitting/evaluation for hearing aids is covered for 2 visits every year. Prescription hearing aids are covered up to $500 per year, but inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
The Astiva Health Premier Plan (HMO) includes vision services like eye exams, routine eye exams (one per year), eyewear with a $300 combined maximum benefit every two years, contact lenses (one pair every two years), eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. There is no copay or coinsurance for these services.
Dental Services See details
Dental Services are covered, with a 20% coinsurance for Medicare Dental Services. Other Dental Services have a maximum benefit of $400 every three months. Oral exams, Dental X-Rays, Prophylaxis (Cleaning), Fluoride Treatment, and Other Preventive Dental Services require prior authorization and have limitations on the number of visits per year or every six months. Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable), Implant Services, Prosthodontics (fixed), and Oral and Maxillofacial Surgery are covered, but Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Insulin, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay, and the coinsurance ranges from 0% to 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Astiva Health Premier Plan (HMO) with prior authorization and a doctor's referral required. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a coinsurance between 0% and 20%, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies and Diabetic Supplies have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the Astiva Health Premier Plan (HMO). Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered, but Diagnostic Radiological Services have a copay of up to $35, and Therapeutic Radiological Services have a coinsurance of up to 20%.
Home Health Services See details
Home Health Services are covered by the Astiva Health Premier Plan (HMO) with no copay and no coinsurance, but require authorization and a referral. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the listed sub-services are covered. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Astiva Health Premier Plan (HMO) with prior authorization and a doctor's referral. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
The Astiva Health Premier Plan (HMO) covers acupuncture with a limit of 72 treatments per year, and also covers Over-the-Counter (OTC) items, but does not cover Nicotine Replacement Therapy (NRT) or Naloxone. The plan also covers a meal benefit for chronic illness with a maximum benefit coverage amount of $600.00 per year. Other services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and others are not covered.
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