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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 Central 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 $3400.00 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 is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For preferred generic drugs, you will pay a $10 copay at a preferred pharmacy, $20 at a standard pharmacy, and no copay for standard mail order. The plan also offers no copay for specialty tier drugs.
Additional Benefits
The Sentara Medicare Value (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services and ambulatory surgical center services have copays as well. The plan also covers ambulance, emergency, and primary care services, with copays applying to some services like specialist visits and chiropractic care. Preventive services, including an annual physical exam, are covered with no copay. The plan includes coverage for hearing, vision, and dental services, with copays or coinsurance applying to some services. Medical equipment, home health, and cardiac rehabilitation are covered with coinsurance or copays, while skilled nursing facility stays have a copay for a limited number of days.
Inpatient Hospital See details
Inpatient Hospital benefits for the Sentara Medicare Value (HMO) plan include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, both of which require prior authorization. For days 1-6, the copay is $285, and days 7-90 have no copay. Additional days for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric 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 all outpatient hospital services and observation services, have a copay of $325.00. Ambulatory Surgical Center (ASC) Services have a $300.00 copay. Outpatient Substance Abuse Services, including individual and group sessions, have a copay between $30.00 and $30.00. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Sentara Medicare Value (HMO) plan, with a $35 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Sentara Medicare Value (HMO) plan. Ground and air ambulance services have a copay of $290. Transportation services to a plan-approved health-related location are covered for up to 36 one-way trips per year. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Services, are covered by the Sentara Medicare Value (HMO) plan. Emergency Services have a $140 copay, while Urgently Needed Services have a $15 copay; both have no coinsurance. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $50 copay.
Primary Care See details
The Sentara Medicare Value (HMO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy with a $20 copay, physician specialist services with a $15 copay, mental health specialty services with a $35 copay for individual and group sessions, physical therapy and speech-language pathology services with a $20 copay, additional telehealth benefits, and opioid treatment program services. Podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for an annual physical exam with no copay. Additional services include 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. 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 of enrollees, telemonitoring services, and counseling services are not covered.
Hearing Services See details
Hearing Services include routine hearing exams with a $15 copay, fitting/evaluation for hearing aids, and prescription hearing aids with a maximum benefit of $2,000 per year; however, prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, nor are OTC hearing aids. Routine hearing exams are limited to one visit per year, and fitting/evaluation for hearing aids is limited to 3 visits per year.
Vision Services See details
The Sentara Medicare Value (HMO) plan covers vision services, including routine eye exams once per year, and eyewear with a combined maximum benefit of $200 per year. Contact lenses and eyeglasses (lenses and frames) are covered, while eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Sentara Medicare Value (HMO) offers dental services with no copay for other dental services, including exams, X-rays, cleanings, and fluoride treatments. Restorative, endodontics, periodontics, removable prosthodontics, and oral and 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, but require 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 Value (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME and Diabetic Supplies have a 20% coinsurance, and Prosthetic Devices and Medical Supplies have a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/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 the following services: Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization is required, and there is a copay for some services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Sentara Medicare Value (HMO) plan, but require prior authorization. You will have no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered, as well as non-Medicare-covered stays, are not covered.
Other Services See details
Other Services include Over-the-Counter (OTC) Items, with a maximum benefit of $139 every three months, and the plan offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit, while 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 are not covered.
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