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Astiva Health Premier Plan - NorCal (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Astiva Health Premier 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 Premier Plan - NorCal (HMO) in 2025, please refer to our full plan details page.
Astiva Health Premier 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 4 out of 5 stars in 2025.
It's important to know that Astiva Health Premier 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 Premier 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 Premier 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.
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 - NorCal (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 pharmacy. For example, preferred generic drugs and specialty tier drugs have no copay at standard pharmacies, while standard generic drugs have a $35 copay. Non-preferred drugs have a 33% coinsurance, and preferred brand drugs have a $95 copay. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for your Part D covered drugs.
Additional Benefits
The Astiva Health Premier Plan - NorCal (HMO) offers a wide range of health benefits. This plan covers inpatient hospital stays with varying copays, outpatient services, and partial hospitalization. Emergency services, primary care, preventive services, and home health services are included, with specific copays and coinsurance amounts depending on the service. Additional benefits include hearing, vision, and dental coverage, as well as home infusion and dialysis services. Medical equipment, diagnostic and radiological services, and skilled nursing facility stays are also covered, with specific cost-sharing requirements. The plan also includes coverage for ambulance and transportation services, and other services like over-the-counter items and meal benefits.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with prior authorization and a doctor's referral required. For Inpatient Hospital-Acute, there is no copay for days 1-4 and days 16-90, but a $100 copay for days 5-15, while Additional Days have no copay; Inpatient Hospital Psychiatric has a $120 copay for days 1-10, and no copay for days 11-90, with Additional Days having no copay.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a $150 copay, ambulatory surgical center services with a $75 copay, and outpatient substance abuse services with a $40 copay for both individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Astiva Health Premier Plan - NorCal (HMO) with a $50 copay. Prior authorization and a doctor referral are required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Astiva Health Premier Plan - NorCal (HMO). Ground ambulance services have a $150 copay, while air ambulance services have a 20% coinsurance. Transportation Services to any health-related location are covered for 24 one-way trips per year.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage are covered by the Astiva Health Premier Plan - NorCal (HMO). Emergency Services have an $85 copay, and there is no coinsurance. Worldwide Emergency Services have a maximum plan benefit coverage of $12,000. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Astiva Health Premier Plan - NorCal (HMO) offers coverage for Primary Care Physician Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services. Occupational Therapy Services have a $20 copay with no coinsurance. Individual and Group Sessions for Psychiatric Services have a $40 copay. Physical Therapy and Speech-Language Pathology Services have a $20 copay with no coinsurance. Opioid Treatment Program Services have a $25 copay. Routine Chiropractic Care and Individual and Group Sessions for Mental Health Specialty Services are not covered, and Podiatry Services are not covered.
Preventive Services See details
Preventive Services are covered, including Medicare-covered zero dollar services. 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, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, home and bathroom safety devices and modifications, and counseling services are not covered. Personal Emergency Response System (PERS) and Fitness Benefit are covered. Kidney Disease Education Services and Other Preventive Services are covered, including Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all of which require prior authorization.
Hearing Services See details
Hearing services include routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams and fitting/evaluation for hearing aids are covered annually, with 1 and 2 visits covered respectively. Prescription hearing aids are covered up to $500 per year for all types, except inner ear, outer ear, and over the ear aids which are not covered.
Vision Services See details
The Astiva Health Premier Plan - NorCal (HMO) covers vision services, including routine eye exams once per year. Eyewear is covered with a combined maximum benefit of $300 per year, and contact lenses are covered with one pair every two years. Eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental services are covered, with a 20% coinsurance for Medicare dental services. Other dental services are covered up to a maximum of $300 every three months.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Astiva Health Premier Plan - NorCal (HMO), including Medicare Part B insulin drugs with a $35 copay and 0-20% coinsurance, and other Medicare Part B drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered under the Astiva Health Premier Plan - NorCal (HMO), but require prior authorization and a doctor's referral. The coinsurance for these services is 20%.
Medical Equipment See details
Medical equipment is covered by the Astiva Health Premier Plan - NorCal (HMO), including Durable Medical Equipment (DME) with a 0-20% coinsurance and Prosthetic Devices, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts, each with a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the Astiva Health Premier Plan - NorCal (HMO). Diagnostic procedures/tests, lab services, and outpatient X-Ray services are not covered. Diagnostic Radiological Services have a copay of up to $50, and Therapeutic Radiological Services have a coinsurance of 20%.
Home Health Services See details
Home Health Services are covered by the Astiva Health Premier Plan - NorCal (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 covered, but none of the sub-services are covered. Prior authorization and a doctor's referral are required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, requiring 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
Other Services include coverage for Over-the-Counter (OTC) Items and Meal Benefits, with OTC items not having a maximum benefit coverage amount, and Meal Benefits having a $600 annual maximum with a doctor referral required. Acupuncture, 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, and Self-Directed Personal Assistance Services are not covered.
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