A non-government entity
Astiva Health Savings Plan - NorCal (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Astiva Health Savings Plan - NorCal (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Astiva Health Savings Plan - NorCal (HMO) in 2026, please refer to our full plan details page.
Astiva Health Savings Plan - NorCal (HMO) is a HMO plan offered by Astiva Health Holdings Incorporated available for enrollment in 2025 to people living in Counties: SCL. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Astiva Health Savings Plan - NorCal (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 Savings Plan - NorCal (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 Savings Plan - NorCal (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. Additionally, this plan comes with a Part B Premium reduction of $165.00. You must continue to pay paying your reduced 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 $3000.00 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:
Sign up for Astiva Health Savings Plan - NorCal (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Astiva Health Savings Plan - NorCal (HMO) features an enhanced alternative drug benefit with no prescription drug deductible. During the initial coverage phase, which lasts until total drug costs reach $2,100, you will pay no copay for Tier 1 preferred generic drugs and Tier 5 specialty drugs at standard pharmacies and through standard mail. Tier 2 standard generic drugs require a $40 copay, while Tier 3 preferred brand drugs have a $95 copay at standard pharmacies. For Tier 4 non-preferred drugs, you will pay a 33% coinsurance at standard pharmacies. Once your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for covered Medicare Part D drugs.
Additional Benefits
The Astiva Health Savings Plan - NorCal (HMO) provides core medical coverage with predictable cost-sharing, including no listed copays or coinsurance for primary care and specialist visits. Emergency care features a ninety-dollar copay and no coinsurance, while outpatient services and inpatient psychiatric stays require set copays but no coinsurance. Additionally, urgent care services and Medicare-covered preventive screenings are available with no copays or coinsurance. For specialized care, the plan offers dental coverage up to three hundred dollars every three months with a twenty percent coinsurance and no copay, alongside a routine annual vision exam and a one hundred twenty-five dollar eyewear allowance every two years. Members also benefit from covered over-the-counter items with no maximum limit, though hearing services and routine transportation are not covered. Finally, durable medical equipment and dialysis services generally require up to twenty percent coinsurance with no copays.
Inpatient Hospital See details
Inpatient hospital benefits are partially covered under the Astiva Health Savings Plan - NorCal (HMO), as upgrades and non-Medicare-covered stays are not covered. Covered psychiatric stays require no coinsurance, with daily copays of $125 for days 1 through 5, $200 for days 6 through 15, and no copay for days 16 through 150.
Outpatient Services See details
Outpatient Services are covered by the Astiva Health Savings Plan - NorCal (HMO), featuring a $100 copay for ambulatory surgical center services and a $40 copay for outpatient substance abuse sessions. These covered services require no coinsurance, and there is no deductible for outpatient blood services.
Partial Hospitalization See details
Astiva Health Savings Plan - NorCal (HMO) covers partial hospitalization benefits with an $80 copay and no coinsurance. Prior authorization and a doctor referral are required to access these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by Astiva Health Savings Plan - NorCal (HMO), as transportation services to health-related locations are not covered. Covered ground ambulance services require a $160 copay and no coinsurance, while air ambulance services require a 20% coinsurance and no copay, with prior authorization required for all ambulance services.
Emergency Services See details
Emergency services are partially covered by Astiva Health Savings Plan - NorCal (HMO) with a $90 copay and no coinsurance, while urgently needed services have no copay and no coinsurance. Worldwide emergency and urgent services are covered up to a $50,000 maximum, but worldwide emergency transportation is not covered.
Primary Care See details
Primary Care benefits are partially covered by the Astiva Health Savings Plan - NorCal (HMO), as podiatry and routine chiropractic care are not covered. Most covered services, including mental health, psychiatry, physical therapy, occupational therapy, and opioid treatment, require a $25 copay and no coinsurance, while chiropractic services have a $15 copay and no coinsurance, and primary care and specialist visits have no listed copay or coinsurance.
Preventive Services See details
Astiva Health Savings Plan - NorCal (HMO) partially covers preventive services, offering Medicare-covered zero-dollar preventive screenings, kidney disease education, and memory fitness with no copays or coinsurance. However, an annual physical exam and most other supplemental benefits—including health education, weight management, and therapeutic massage—are not covered.
Hearing Services See details
Hearing services are not covered under the Astiva Health Savings Plan - NorCal (HMO). There is no coverage for routine hearing exams, fitting and evaluation for hearing aids, prescription hearing aids, or over-the-counter hearing aids.
Vision Services See details
Vision services are partially covered by Astiva Health Savings Plan - NorCal (HMO), which features no deductible and covers one routine eye exam every year. The plan also provides a combined maximum benefit of $125 every two years for contact lenses and eyeglasses, though eyewear upgrades are not covered.
Dental Services See details
Astiva Health Savings Plan - NorCal (HMO) partially covers dental services, offering Medicare-covered dental care with a 20% coinsurance and no copay. Preventive and comprehensive dental services are covered up to $300 every three months, though maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Astiva Health Savings Plan - NorCal (HMO) covers Home Infusion bundled Services with prior authorization, offering no copay and no coinsurance to 20% coinsurance for Medicare Part B chemotherapy, radiation, and other drugs. Medicare Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Astiva Health Savings Plan - NorCal (HMO) covers dialysis services with no copay and a 20% coinsurance. A doctor referral and prior authorization are required to receive these covered services.
Medical Equipment See details
Astiva Health Savings Plan - NorCal (HMO) covers medical equipment with no copays, though prior authorization is required for most services. Members pay a coinsurance of 0% to 20% for durable medical equipment (DME) and diabetic supplies, and a flat 20% coinsurance for prosthetics, medical supplies, and diabetic therapeutic shoes.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered under the Astiva Health Savings Plan - NorCal (HMO), while diagnostic procedures, lab services, and outpatient X-rays are not covered. Covered diagnostic radiological services require no coinsurance and a copay ranging from no copay to $50, whereas therapeutic radiological services require a 20% coinsurance and a copay, with both requiring a doctor referral and prior authorization.
Home Health Services See details
Home Health Services are covered under the Astiva Health Savings Plan - NorCal (HMO), requiring prior authorization and a doctor referral. Specific copay and coinsurance cost-sharing details are not provided for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered under the Astiva Health Savings Plan - NorCal (HMO), which states some services are covered, though Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered in practice. Since these services are not covered, there is no copay and no coinsurance for members.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by Astiva Health Savings Plan - NorCal (HMO) because additional days beyond Medicare-covered stays are not covered. Prior authorization and a doctor referral are required, and while specific copay and coinsurance amounts are not specified, there is no cost sharing on the day of discharge.
Other Services See details
Other Services are partially covered under the Astiva Health Savings Plan - NorCal (HMO), which features coverage for over-the-counter (OTC) items with no maximum benefit limit, while acupuncture, meal benefits, and dual eligible SNP services are not covered. Covered OTC items are obtained via reimbursement with no copay or coinsurance specified, though nicotine replacement therapy and naloxone are excluded from this benefit.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved