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Astiva Health C-SNP WOW - NorCal (HMO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Astiva Health C-SNP WOW - NorCal (HMO C-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Astiva Health C-SNP WOW - NorCal (HMO C-SNP) in 2025, please refer to our full plan details page.
Astiva Health C-SNP WOW - NorCal (HMO C-SNP) is a HMO C-SNP 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 C-SNP WOW - NorCal (HMO C-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Astiva Health C-SNP WOW - NorCal (HMO C-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Astiva Health C-SNP WOW - NorCal (HMO C-SNP).
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 C-SNP WOW - NorCal (HMO C-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $29.70. 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 $590.00 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 $9350.00 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 C-SNP WOW - NorCal (HMO C-SNP) plan has a $590 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, standard generic drugs have a $15 copay at a standard pharmacy, and preferred brand drugs have a $100 copay. In the initial coverage phase, you pay these costs until your total drug costs reach $2000. After this, in the catastrophic coverage phase, you pay nothing for covered Part D drugs. The plan's premium may be reduced if you qualify for the low-income subsidy.
Additional Benefits
The Astiva Health C-SNP WOW - NorCal (HMO C-SNP) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services generally have a 20% coinsurance. Emergency services have a $70 copay, and primary care visits have a copay. Preventive services are covered with no copay, and the plan includes additional benefits like vision, hearing, and dental services, each with specific coverage limits and cost-sharing arrangements. The plan also covers home health services, skilled nursing facilities, and medical equipment with varying copays and coinsurance.
Inpatient Hospital See details
The Astiva Health C-SNP WOW - NorCal (HMO C-SNP) plan covers Inpatient Hospital services, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a copay (see plan details). Additional days for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric have a copay of $816 for days 91-150, with 60 additional days per benefit period. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered, including outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital and observation services have a 20% coinsurance, while individual and group sessions for outpatient substance abuse have a minimum 20% coinsurance. Ambulatory Surgical Center (ASC) Services also have a minimum 20% coinsurance. Outpatient blood services include an enhanced benefit with a three-pint deductible waived.
Partial Hospitalization See details
Partial Hospitalization is covered with a $80 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 C-SNP WOW - NorCal (HMO C-SNP) plan, with prior authorization required for all ambulance services. Ground ambulance services have a $200 copay, while air ambulance services have 20% coinsurance. Transportation Services - Any Health-related Location is covered for 24 one-way trips per year using bus/subway or medical transport. Transportation Services - Plan Approved Health-related Location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered, with a $70 copay for Emergency Services and no coinsurance. Worldwide Emergency Services has a maximum plan benefit coverage of $12,000. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Astiva Health C-SNP WOW - NorCal (HMO C-SNP) plan covers primary care physician services, chiropractic services with 20% coinsurance, occupational therapy services with 20% coinsurance, physician specialist services, mental health specialty services with a $50 copay for individual and group sessions, psychiatric services with a $45 copay for individual and group sessions, physical therapy and speech-language pathology services with 20% coinsurance, additional telehealth benefits, and opioid treatment program services with a $15 copay. Podiatry services are not covered.
Preventive Services See details
The Astiva Health C-SNP WOW - NorCal (HMO C-SNP) plan covers preventive services, including Medicare-covered services with no copay, and additional preventive services like Personal Emergency Response Systems (PERS) and Fitness Benefits. The plan does not cover annual physical exams.
Hearing Services See details
Hearing services include routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams are covered for one visit per year, fitting/evaluation for hearing aids are covered for two visits per year, and prescription hearing aids (all types) are covered for two per year with a maximum plan benefit of $500 per year; inner ear, outer ear, and over the ear hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams, eyewear, and upgrades. Routine eye exams are covered once per year. Eyewear has a combined maximum plan benefit coverage of $300 every two years, including contact lenses (one pair every two years), eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames.
Dental Services See details
Dental services are covered, with a 20% coinsurance for Medicare Dental Services, which require prior authorization and a doctor's referral. Other Dental Services have a maximum benefit of $350 every three months. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and fluoride treatments are covered annually, with limited visits per year. Orthodontic Services are covered under Diagnostic and Preventive Dental. Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, 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.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization and a doctor referral. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment is covered by the Astiva Health C-SNP WOW - NorCal (HMO C-SNP) plan, including Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, and Prosthetics/Medical Supplies, 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 covered, with no copay. Diagnostic Procedures/Tests, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services have a coinsurance of at most 20%, while Lab Services are not covered.
Home Health Services See details
Home Health Services are covered by the Astiva Health C-SNP WOW - NorCal (HMO C-SNP) plan with no copay or coinsurance, but prior authorization and a referral are required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but not Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization and a doctor's referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization and a doctor referral. For days 1-20, there is no copay, but for days 21-100, the copay is $214. Additional days beyond Medicare-covered SNF stays and non-Medicare-covered SNF stays are not covered.
Other Services See details
The Astiva Health C-SNP WOW - NorCal (HMO C-SNP) plan does not cover 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, or Self-Directed Personal Assistance Services. Over-the-Counter (OTC) Items and Meal Benefit are covered, with the meal benefit requiring a doctor's referral and offering up to $600 per year.
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