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Sentara Medicare Prime (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Sentara Medicare Prime (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Sentara Medicare Prime (HMO) in 2025, please refer to our full plan details page.
Sentara Medicare Prime (HMO) is a HMO plan offered by Sentara Health Care (SHC) available for enrollment in 2025 to people living in Greater Hampton Roads Area. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Sentara Medicare Prime (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 Sentara Medicare Prime (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 Sentara Medicare Prime (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $75.00. 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 a $130.00 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 $3500.00 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 Sentara Medicare Prime (HMO) plan has a $130 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, in the initial coverage phase, preferred generic drugs have an $8 copay at preferred pharmacies and a $0 copay at standard mail pharmacies. The plan offers a "Enhanced Alternative" drug benefit. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs. If you qualify for the low-income subsidy, you will pay $18.70 for Part D.
Additional Benefits
The Sentara Medicare Prime (HMO) plan offers coverage for a variety of services, including inpatient and outpatient hospital care with associated copays. You can also expect coverage for emergency services with a copay, and primary care physician visits with a copay. Additional benefits include hearing, vision, and dental services, with specific copays or coinsurance depending on the service. This plan also includes coverage for preventive services, home health, and medical equipment, with some services requiring prior authorization and having associated costs. The plan also has coverage for ambulance services, home infusion, and skilled nursing facility services. However, it's important to note that certain services like cardiac rehabilitation, and additional hours of care are not covered.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you pay a $190 copay for days 1-8, and no copay for days 9-90. Additional days for both are covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including Outpatient Hospital Services and Observation Services, have a $190 copay, while Ambulatory Surgical Center (ASC) Services have a $220 copay. Outpatient Substance Abuse Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Sentara Medicare Prime (HMO) plan, but requires prior authorization. You will have a $35 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Sentara Medicare Prime (HMO) plan, with prior authorization required. Both ground and air ambulance services have a copay of $265.00, and transportation services to a plan-approved health-related location are covered for up to 48 one-way trips per year.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Services, are covered. Emergency Services have a $140 copay and no coinsurance, while Urgently Needed Services have a $20 copay and no coinsurance. Worldwide Emergency Services has a maximum plan benefit coverage of $50,000.
Primary Care See details
Primary Care Physician Services are covered. Chiropractic Services have a $10 copay for routine care. Occupational Therapy Services are covered and have a $10 copay. Physician Specialist Services have a $5 copay. Mental Health Specialty Services have a $15 copay for individual and group sessions. Physical Therapy and Speech-Language Pathology Services have a $10 copay. Other covered benefits include Additional Telehealth Benefits and Opioid Treatment Program Services. Podiatry Services are not covered.
Preventive Services See details
The Sentara Medicare Prime (HMO) plan covers preventive services, including Medicare-covered services with prior authorization, annual physical exams, additional preventive services, health education, personal emergency response systems, re-admission prevention, nutritional/dietary benefits, in-home support services, additional sessions of smoking and tobacco cessation counseling, fitness benefits, enhanced disease management, remote access technologies, home and bathroom safety devices, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following welcome visits. However, in-home safety assessments, medical nutrition therapy, post-discharge in-home medication reconciliation, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, home-based palliative care, support for caregivers, telemonitoring services, and counseling services are not covered.
Hearing Services See details
Hearing exams are covered with a $10 copay, and routine hearing exams are limited to one per year, while fitting/evaluation for hearing aids are limited to three per year. Prescription hearing aids are covered up to a maximum of $2000 per year, however, 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 once per year, contact lenses, and eyeglasses (lenses and frames), with a combined maximum benefit of $200 per year for eyewear; eyeglass lenses, eyeglass frames, and upgrades are not covered. There is no copay or coinsurance for these services.
Dental Services See details
The Sentara Medicare Prime (HMO) plan covers dental services, including oral exams, dental x-rays, prophylaxis (cleaning), fluoride treatment, and orthodontic services, with no copay for other dental services. Restorative, adjunctive general, endodontics, periodontics, prosthodontics (removable and fixed), implant services, and oral and maxillofacial surgery require a $50 copay, while maxillofacial prosthetics and orthodontics are not covered. Orthodontic services have a maximum plan benefit of $3,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered with prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis services are covered under the Sentara Medicare Prime (HMO) plan. You will pay 20% coinsurance for dialysis services.
Medical Equipment See details
Medical Equipment benefits with the Sentara Medicare Prime (HMO) plan include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, and Durable Medical Equipment for use outside the home is not covered. Prosthetic devices and diabetic supplies and therapeutic shoes/inserts have a 20% coinsurance, while medical supplies have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services with a copay for Medicare-covered lab services, and diagnostic procedures/tests with a copay between $0 and $80.00. Therapeutic Radiological Services are covered with a copay of up to $10.00 and a coinsurance of up to 20%, while Diagnostic Radiological Services have a copay of up to $270.00. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Sentara Medicare Prime (HMO) plan with no copay or coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Sentara Medicare Prime (HMO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Sentara Medicare Prime (HMO), but require prior authorization. There is no copay for days 1-20, and a $214 copay for days 21-100; additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Sentara Medicare Prime (HMO) plan covers Over-the-Counter (OTC) items with a maximum benefit of $100 every three months, including Nicotine Replacement Therapy (NRT), but does not cover acupuncture, meal benefits, or various other services. Other services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and more are not covered.
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