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Senior Health Plan Platinum (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Senior Health Plan Platinum (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Senior Health Plan Platinum (HMO) in 2025, please refer to our full plan details page.
Senior Health Plan Platinum (HMO) is a HMO plan offered by St Francis Health System & St John Health System available for enrollment in 2025 to people living in Select counties in N.E. and Central Oklahoma. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Senior Health Plan Platinum (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 Senior Health Plan Platinum (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 Senior Health Plan Platinum (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $19.00. 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3900.00 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 Senior Health Plan Platinum (HMO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay varying copays or coinsurance depending on the drug tier and pharmacy. For example, you'll pay a $5 copay at a standard pharmacy for preferred generic drugs, while standard mail orders have no copay for the same drug. After your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs. This plan offers an enhanced alternative drug benefit.
Additional Benefits
The Senior Health Plan Platinum (HMO) offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services and emergency services have copays depending on the service. The plan also covers primary care with no copay, and covers hearing, vision, and dental services with copays or coinsurance. Additional benefits include coverage for ambulance and transportation services, home health services with no copay, and medical equipment. The plan also provides coverage for prescription hearing aids, OTC hearing aids, and eyewear. However, some services like cardiac rehabilitation and certain dental and vision procedures may not be covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with prior authorization and a doctor's referral. For days 1-5, the copay is $235, and days 6-90 have no copay; there is no coinsurance. 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, observation services, and ambulatory surgical center services, have a $225 copay. Outpatient substance abuse individual and group sessions have a copay of $20. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Senior Health Plan Platinum (HMO) plan, with a $50 copay. Prior authorization and a doctor referral are required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including both ground and air ambulance services with a $250 copay per service. Transportation Services to a Plan Approved Health-related Location are covered for 12 one-way trips per year via taxi or medical transport.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Senior Health Plan Platinum (HMO). Emergency Services has a $90 copay, Urgently Needed Services has a $25 copay, and Worldwide Emergency Coverage has a $90 copay, Worldwide Urgent Coverage has a $25 copay, and Worldwide Emergency Transportation has a $250 copay. There is no coinsurance for any of these services.
Primary Care See details
The Senior Health Plan Platinum (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $10 copay, and specialist services with a $25 copay. Mental health specialty services, including individual and group sessions, have a $20 copay, while physical therapy and speech-language pathology services have a $10 copay, and additional telehealth benefits have a copay between $0 and $25. Opioid treatment program services have a $20 copay.
Preventive Services See details
The Senior Health Plan Platinum (HMO) covers Medicare-covered preventive services, annual physical exams, additional preventive services, kidney disease education, and other preventive services, with some services requiring a doctor's referral. Health education, in-home safety assessments, medical nutrition therapy, post discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
The Senior Health Plan Platinum (HMO) plan covers hearing exams, including routine hearing exams once per year, and fitting/evaluation for hearing aids once every two years. This plan also covers prescription hearing aids (all types) with a maximum benefit of $500 every two years and OTC hearing aids with a maximum benefit of $500 every two years. Prescription hearing aids - inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision services include routine eye exams with one exam covered every year, and eyewear with a combined maximum plan benefit coverage of $400 every year. Contact lenses and eyeglasses (lenses and frames) are also covered, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Senior Health Plan Platinum (HMO) plan covers Medicare dental services with a $25 copay, and other dental services including oral exams, dental x-rays, prophylaxis (cleaning), fluoride treatment, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable), and oral and maxillofacial surgery. Orthodontic services are covered up to a maximum of $1500 per year, while maxillofacial prosthetics, implant services, prosthodontics (fixed), and orthodontics are not covered. Endodontics and prosthodontics (removable) have a 50% coinsurance.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Senior Health Plan Platinum (HMO) plan, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while the coinsurance for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Senior Health Plan Platinum (HMO), but require prior authorization and a doctor referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered by the Senior Health Plan Platinum (HMO). DME has a coinsurance between 0% and 15%, and Prosthetic Devices and Medical Supplies have a 20% coinsurance, while Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Senior Health Plan Platinum (HMO) plan. Diagnostic Procedures/Tests have a copay between $0 and $100, and Diagnostic Radiological Services have a copay up to $100; however, Lab Services, Therapeutic Radiological Services, and Outpatient X-Ray Services are not covered.
Home Health Services See details
Home Health Services are covered with no copay and no coinsurance, but require prior authorization and a referral. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Senior Health Plan Platinum (HMO). This includes Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Senior Health Plan Platinum (HMO) with prior authorization and a doctor referral required. There is no copay for days 1-20, and a $140 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items and Other 1 benefits. The plan provides up to $85 every three months for OTC items, including nicotine replacement therapy and Naloxone, and does not cover acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, or various other services.
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