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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 2026, 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 2026 to people living in Counties: OC, LA, RIV, SB, SD. This plan received an overall rating of 3.5 out of 5 stars in 2026.
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) offers an Enhanced Alternative drug benefit with no prescription drug deductible. During the initial coverage phase, you pay no copay for Tier 1 preferred generic drugs and Tier 5 specialty drugs at standard pharmacies. Tier 2 standard generics require a $35 copay, Tier 3 preferred brands require a $95 copay, and Tier 4 non-preferred drugs carry a 33% coinsurance. After your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for covered Part D drugs. Additionally, qualifying for the low-income subsidy can reduce your Part D premium to $0.
Additional Benefits
The Astiva Health Premier Plan (HMO) offers comprehensive medical coverage, featuring no copay for inpatient hospital stays during days 1 through 5 and 16 through 90, alongside no copay for urgently needed services. Emergency room visits carry a $75 copay which is waived if admitted, and primary care services are provided with no coinsurance. Standard preventive services are also fully covered with no copay and no coinsurance. Specialty benefits include routine vision and hearing exams with no deductibles, offering up to $500 annually per ear for prescription hearing aids and a $300 eyewear allowance every two years. Dental benefits are covered with no copay or coinsurance up to $350 every three months, and ground ambulance services require a $50 copay while 24 one-way routine transportation trips are covered with no copay. Additionally, durable medical equipment is available with no copay, though coinsurance ranges from no coinsurance to 20%.
Inpatient Hospital See details
Inpatient hospital services are partially covered by the Astiva Health Premier Plan (HMO) with no coinsurance, though upgrades and non-Medicare-covered stays are not covered. Covered acute stays have no copay for days 1–5 and 16–90, with a $150 copay for days 6–15, while psychiatric stays have no copay except for a $180 copay for days 6–15.
Outpatient Services See details
Astiva Health Premier Plan (HMO) covers outpatient services, including outpatient hospital, observation, and ambulatory surgical center services, which require prior authorization and a doctor referral. Covered outpatient substance abuse sessions incur a $15 copay and no coinsurance, while outpatient blood services are provided with no deductible.
Partial Hospitalization See details
Astiva Health Premier Plan (HMO) covers partial hospitalization benefits with a $50 copay and no coinsurance. This covered service requires both prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered under the Astiva Health Premier Plan (HMO), though transportation is only partially covered because plan-approved health-related location services are excluded. Ground ambulance services require a $50 copay and no coinsurance, air ambulance services require a 20% coinsurance and no copay, and up to 24 annual one-way transportation trips to any health-related location are covered with no copay or coinsurance.
Emergency Services See details
Astiva Health Premier Plan (HMO) covers emergency services with a $75 copay and no coinsurance, which is waived if admitted to the hospital within 48 hours, and urgently needed services with no copay and no coinsurance. Worldwide emergency services are partially covered up to a $100,000 maximum benefit, which includes worldwide emergency and urgent coverage but excludes worldwide emergency transportation.
Primary Care See details
Astiva Health Premier Plan (HMO) provides partially covered Primary Care benefits with no coinsurance, featuring a $25 copay for psychiatric services and a $15 copay for opioid treatment. While many services are covered, podiatry and routine chiropractic care are not covered, and although some mental health specialty services are covered, individual and group sessions are not.
Preventive Services See details
Preventive services are partially covered by the Astiva Health Premier Plan (HMO), which offers Medicare-covered zero-dollar preventive benefits with no copay and no coinsurance. However, several sub-services are not covered, including annual physical exams, health education, in-home safety assessments, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, additional smoking cessation, disease management, telemonitoring, remote access, bathroom safety modifications, and counseling.
Hearing Services See details
Astiva Health Premier Plan (HMO) partially covers hearing services with no deductible, offering one routine hearing exam and two fitting evaluations annually, plus up to $500 per ear yearly for prescription hearing aids. However, OTC hearing aids, as well as prescription hearing aids for the inner ear, outer ear, and over the ear, are not covered.
Vision Services See details
Astiva Health Premier Plan (HMO) covers vision services with no deductibles, including one routine eye exam every year and a $300 combined maximum benefit every two years for contacts and eyeglasses, though eyewear upgrades are not covered.
Dental Services See details
Dental services are partially covered by the Astiva Health Premier Plan (HMO), which excludes maxillofacial prosthetics and orthodontics. Medicare-covered dental services require a 20% coinsurance and no copay, while other covered dental services have no copay or coinsurance up to a maximum benefit of $350 every three months.
Home Infusion bundled Services See details
Astiva Health Premier Plan (HMO) covers home infusion bundled services with prior authorization, requiring no copay and no coinsurance to 20% coinsurance for chemotherapy, radiation, and other Part B drugs. Medicare Part B insulin drugs are covered with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Astiva Health Premier Plan (HMO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to receive these covered services.
Medical Equipment See details
Medical equipment is covered by the Astiva Health Premier Plan (HMO) with no copays, though prior authorization is required. Members will pay no coinsurance to 20% coinsurance for durable medical equipment (DME) and diabetic supplies, and 20% coinsurance for prosthetics, medical supplies, and diabetic therapeutic shoes or inserts.
Diagnostic and Radiological Services See details
Astiva Health Premier Plan (HMO) partially covers diagnostic and radiological services with no coinsurance, requiring prior authorization and doctor referrals. Diagnostic radiological services are covered with a copay of $0 to $30, while diagnostic procedures, lab services, therapeutic radiological services, and outpatient X-ray services are not covered.
Home Health Services See details
Home Health Services are covered under the Astiva Health Premier Plan (HMO), requiring both prior authorization and a doctor referral.
Cardiac Rehabilitation Services See details
Astiva Health Premier Plan (HMO) indicates that some Cardiac Rehabilitation Services are covered, but in practice, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered. Consequently, there are no copays or coinsurance costs for these services under this plan.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are partially covered by the Astiva Health Premier Plan (HMO), requiring prior authorization and a doctor referral but no prior hospital stay. Copay and coinsurance details are not specified, though no cost-sharing is charged on the day of discharge, and additional days beyond Medicare-covered SNF care are not covered.
Other Services See details
Astiva Health Premier Plan (HMO) covers acupuncture for up to 16 treatments every three months and offers an annual meal benefit of up to $600 for chronic illnesses with a doctor referral. Over-the-counter items are partially covered, excluding nicotine replacement therapy and naloxone, while dual eligible SNPs with highly integrated services are not covered.
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