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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 $65.00. 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 $130.00 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy you use. In the initial coverage phase, copays vary from $8.00 to $95.00 depending on the drug tier and pharmacy, while non-preferred drugs have a 31% coinsurance. Once your total drug costs reach $2000.00, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The Sentara Medicare Prime (HMO) plan offers comprehensive coverage, including inpatient hospital stays with a $190 copay for days 1-8, and no copay for days 9-90. Outpatient services have a $190 copay, while emergency services have a $140 copay. The plan includes coverage for primary care, hearing exams with a $10 copay, routine eye exams, and dental services with no copay for many services. This plan also provides coverage for ambulance services with a $265 copay, and home health services with no copay. Additionally, it offers benefits like a $100 allowance every three months for over-the-counter items. However, some services like outpatient substance abuse, podiatry, and certain vision and dental services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered by Sentara Medicare Prime (HMO). For inpatient hospital-acute and inpatient hospital psychiatric care, you pay a $190 copay for days 1-8, and no copay for days 9-90. Additional days for both inpatient hospital-acute and inpatient hospital psychiatric care have 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 and observation services, are covered by Sentara Medicare Prime (HMO) with a $190 copay. Ambulatory Surgical Center (ASC) Services have a $220 copay, and Outpatient Blood Services are also covered. Outpatient Substance Abuse Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by Sentara Medicare Prime (HMO) with a $35 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Sentara Medicare Prime (HMO), with a $265 copay for both ground and air ambulance services; other transportation services to plan-approved health-related locations are covered for up to 48 one-way trips per year. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Sentara Medicare Prime (HMO) plan. 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
Sentara Medicare Prime (HMO) covers primary care physician services, chiropractic services with a $10 copay, occupational therapy services with a $10 copay, physician specialist services with a $5 copay, mental health specialty services with a $15 copay for individual and group sessions, psychiatric services with a $15 copay for individual and group sessions, physical therapy and speech-language pathology services with a $10 copay, additional telehealth benefits, and opioid treatment program services. Podiatry services are not covered.
Preventive Services See details
The Sentara Medicare Prime (HMO) plan covers a variety of preventive services, including Medicare-covered services, annual physical exams, 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 a welcome visit. Some preventive services, like in-home safety assessments, medical nutrition therapy, post-discharge in-home medication reconciliation, wigs for chemotherapy-related hair loss, 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 services include coverage for hearing exams with a $10 copay, and routine hearing exams and fitting/evaluation for hearing aids are also covered. Prescription hearing aids are covered up to a maximum of $2000 per year, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, nor are OTC hearing aids.
Vision Services See details
Vision services include routine eye exams once per year, with no deductible. Eyewear is covered up to a combined maximum of $200 per year, and contact lenses and eyeglasses (lenses and frames) are covered. However, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Sentara Medicare Prime (HMO) covers dental services with no copay for other dental services, and for Oral Exams, Dental X-Rays, Prophylaxis (Cleaning), and Fluoride Treatment. Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Implant Services, and Oral and Maxillofacial Surgery have a $50 copay. Orthodontic Services are covered up to a maximum of $3,000 per year, while Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. For Medicare Part B Insulin Drugs, there is a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is 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 these services.
Medical Equipment See details
Medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment, is covered by the Sentara Medicare Prime (HMO) plan. Durable medical equipment has a 20% coinsurance and requires authorization, while durable medical equipment for use outside the home is not covered. Prosthetic devices and diabetic supplies have a 20% coinsurance, and medical supplies have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Sentara Medicare Prime (HMO) plan, with Diagnostic Procedures/Tests having a copay between $0 and $80, and Diagnostic Radiological Services having a copay up to $270. Therapeutic Radiological Services have a coinsurance up to 20% and a copay up to $10, while Outpatient X-Ray Services have no copay. Lab Services are not covered.
Home Health Services See details
Home Health Services are covered by Sentara Medicare Prime (HMO), with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the specific Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization is required.
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
Other Services in 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, 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.
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