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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 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 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 $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 Value (HMO) plan has a $150 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, you will pay a $10 copay for preferred generic drugs at a preferred pharmacy, and a $0 copay for preferred mail order generic drugs. The plan covers specialty tier drugs with no copay.
Additional Benefits
The Sentara Medicare Value (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $285 copay for days 1-7, and no copay for days 8-90. Outpatient services have copays ranging from $200 to $325, while primary care and specialist visits have copays between $10 and $25. This plan also covers ambulance services with a $290 copay, and offers transportation services with no copay for up to 36 one-way trips per year. Hearing services include hearing exams with a $15 copay, and coverage for hearing aids. Vision services cover routine eye exams, and eyewear with a combined maximum benefit of $200 per year. Dental services include a $35 copay for restorative services, and orthodontic services up to a maximum of $2500 per year.
Inpatient Hospital See details
The Sentara Medicare Value (HMO) plan covers inpatient hospital stays, including acute and psychiatric care. For days 1-7, there is a $285 copay, and for days 8-90, there is no copay. Additional days for both acute and psychiatric care are covered with no copay.
Outpatient Services See details
Outpatient Services are covered by the Sentara Medicare Value (HMO) plan, including outpatient hospital services, observation services, ambulatory surgical center services, and outpatient blood services. Outpatient hospital and observation services have a $325 copay, ambulatory surgical center services have a $200 copay, and outpatient blood services have a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered under 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, while transportation services to a plan-approved health-related location are covered for up to 36 one-way trips per year with no copay or coinsurance. 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 by the Sentara Medicare Value (HMO) plan. Emergency Services have a $140 copay, Urgently Needed Services have a $15 copay, and Worldwide Emergency Services have a $50 copay for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation, with a maximum plan benefit coverage of $50,000.
Primary Care See details
Sentara Medicare Value (HMO) covers primary care physician services, chiropractic services with a $10 copay, occupational therapy with a $20 copay, physician specialist services with a $15 copay, and mental health specialty services with a $25 copay for individual and group sessions. The plan also covers other health care professionals with a copay ranging from $0 to $25, psychiatric services with a $25 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. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services are covered, including Medicare-covered zero dollar preventive services, annual physical exams, and additional preventive services; 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, and counseling services are not covered. Other covered services include health education, personal emergency response system, re-admission prevention, nutritional/dietary benefit, in-home support services, additional sessions of smoking and tobacco cessation counseling, fitness benefit, enhanced disease management, remote access technologies, home and bathroom safety devices and modifications, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following welcome visit.
Hearing Services See details
Hearing Services include coverage for hearing exams with a $15 copay, routine hearing exams (1 per year), fitting/evaluation for hearing aids (3 per year), and prescription hearing aids (all types, 2 per year, up to $2000 per year). Prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include coverage for routine eye exams with one exam covered every year, and eyewear. Eyewear coverage includes contact lenses and eyeglasses (lenses and frames) with a combined maximum benefit of $200 per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Sentara Medicare Value (HMO) covers Other Dental Services with no copay. Medicare Dental Services, Oral Exams, Dental X-Rays, Prophylaxis (Cleaning), Fluoride Treatment, and Oral and Maxillofacial Surgery require prior authorization. Restorative Services, Adjunctive General Services, Endodontics, Periodontics, and Prosthodontics (removable) require a $35 copay. Orthodontic Services are covered up to a maximum of $2500 per year, while Maxillofacial Prosthetics, Implant Services, Prosthodontics (fixed), and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Sentara Medicare Value (HMO) plan, with a $35 copay for Medicare Part B Insulin Drugs, and coinsurance between 0-20% for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs. Prior authorization is required.
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) with a 20% coinsurance, prosthetics/medical supplies with a 20% coinsurance, and diabetic equipment with a 20% coinsurance for covered services. 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 $285. Therapeutic Radiological Services have a copay up to $15 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 by the Sentara Medicare Value (HMO) plan, but the specific cardiac rehabilitation services are not covered. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Sentara Medicare Value (HMO) plan. You will have no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for Skilled Nursing Facility (SNF) are not covered.
Other Services See details
Under the Sentara Medicare Value (HMO) plan, 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. This plan covers Over-the-Counter (OTC) Items with a maximum benefit coverage amount of $130.00 every three months, and offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit.
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