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Sentara Medicare Value (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Sentara Medicare Value (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Sentara Medicare Value (HMO) in 2025, please refer to our full plan details page.
Sentara Medicare Value (HMO) is a HMO plan offered by Sentara Health Care (SHC) available for enrollment in 2025 to people living in Northern Virginia. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Sentara Medicare Value (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 Value (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 Value (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 a $150.00 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 $4300.00 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 Value (HMO) plan has a $150 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For example, for a 30-day supply, preferred generic drugs have a $10 copay at preferred pharmacies, while standard mail orders have no copay. Non-preferred drugs have a 31% coinsurance, and specialty tier drugs have no copay.
Additional Benefits
The Sentara Medicare Value (HMO) plan offers coverage for a wide range of services, including inpatient and outpatient hospital care, with varying copays. You will also have access to primary care, hearing, vision, and dental services, as well as ambulance and transportation services. Many preventive services are covered, and you can also get home health services with no copay. This plan provides coverage for emergency services, and offers benefits such as home infusion and dialysis services. The plan also covers medical equipment, and diagnostic and radiological services. However, some services, such as certain dental and vision procedures, and some additional services, are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, each with a $275 copay for days 1-5 and no copay for days 6-90. Additional days for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric 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 include coverage for outpatient hospital services and observation services with a $280 copay, ambulatory surgical center services with a $200 copay, and outpatient blood services. Individual and group sessions for outpatient substance abuse are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Sentara Medicare Value (HMO) plan, with a $35 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Sentara Medicare Value (HMO) plan. Ground and Air Ambulance Services have a $265 copay, with no coinsurance. Transportation Services to a plan-approved health-related location are covered for up to 36 one-way trips per year, while transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Sentara Medicare Value (HMO) plan. Emergency Services have a $125 copay, and Urgently Needed Services have a $15 copay, while Worldwide Emergency Services have a $50 copay.
Primary Care See details
The Sentara Medicare Value (HMO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $25 copay, physician specialist services with a $15 copay, mental health specialty services with a $25 copay for individual and group sessions, other health care professional services with a copay between $0 and $25, psychiatric services with a $25 copay for individual and group sessions, physical therapy and speech-language pathology services with a $25 copay, additional telehealth benefits, and opioid treatment program services. Podiatry services are not covered.
Preventive Services See details
The Sentara Medicare Value (HMO) plan covers preventive services including Medicare-covered zero-dollar preventive services, an annual physical exam, health education, Personal Emergency Response System (PERS), re-admission prevention, nutritional/dietary benefits, in-home support services, additional sessions of smoking and tobacco cessation counseling, a fitness benefit, 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; 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, and counseling services are not covered. Some services require prior authorization.
Hearing Services See details
Hearing services are covered, including hearing exams with a $20 copay, routine hearing exams (1 per year), and fitting/evaluation for hearing aids (3 per year). Prescription hearing aids are covered up to $2,000 per year, with 2 visits per year for all types of hearing aids; however, prescription hearing aids for the inner, outer, and over-the-ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams, contact lenses, and eyeglasses (lenses and frames), with no deductible. Routine eye exams are covered once per year. Eyewear has a combined maximum benefit of $200 per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Sentara Medicare Value (HMO) plan covers a range of dental services, including oral exams, dental X-rays, and cleanings, with no copay. Restorative services, adjunctive general services, endodontics, periodontics, prosthodontics, and oral/maxillofacial surgery have a $35 copay, while maxillofacial prosthetics, implant services, prosthodontics (fixed), and orthodontics are not covered. Orthodontic services have a maximum plan benefit of $2,500 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. 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 Value (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, diagnostic procedures and tests (with a copay between $0 and $85), and diagnostic radiological services (with a copay up to $275). Therapeutic radiological services have a copay up to $25 and a coinsurance of 20%, while outpatient X-ray services have no copay. Lab services are not covered.
Home Health Services See details
Home Health Services are covered by the Sentara Medicare Value (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Sentara Medicare Value (HMO). 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 SNF stays are not covered.
Other Services See details
Other Services include Over-the-Counter (OTC) Items, with a maximum benefit coverage amount of $181.00 every three months; however, acupuncture, meal benefit, 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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