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Covenant Health Advantage Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Covenant Health Advantage Rx (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Covenant Health Advantage Rx (HMO) in 2025, please refer to our full plan details page.
Covenant Health Advantage Rx (HMO) is a HMO plan offered by Baylor Scott & White Holdings available for enrollment in 2025 to people living in West Texas. The overall rating for this plan is not yet available for 2025.
It's important to know that Covenant Health Advantage Rx (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 Covenant Health Advantage Rx (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 Covenant Health Advantage Rx (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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $5900.00 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 Covenant Health Advantage Rx (HMO) plan has an enhanced alternative drug benefit. The plan has no deductible. In the initial coverage phase, you can expect to pay $5 for preferred generic drugs at a preferred pharmacy, $10 at a standard pharmacy, and no copay for standard mail. Standard generic drugs have a $47 copay. Preferred and standard brand drugs have a $100 copay. Non-preferred drugs have 33% coinsurance. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you will pay nothing for covered drugs.
Additional Benefits
The Covenant Health Advantage Rx (HMO) plan offers a range of benefits, including inpatient hospital stays with copays, outpatient services with copays and coinsurance, and coverage for ambulance services with a $300 copay. The plan also covers primary care, preventive services with no copay, and hearing and vision services with copays and allowances for eyewear and hearing aids. Dental services are covered with a $3,000 annual maximum, but certain services are not covered. Additional benefits include home infusion, dialysis with 20% coinsurance, and medical equipment with coinsurance. The plan also covers diagnostic and radiological services, home health services with no copay, and skilled nursing facility stays with a copay after the first 20 days. Other services include OTC items, but note that some services are not covered, such as cardiac rehabilitation services, and additional hours of care.
Inpatient Hospital See details
Inpatient Hospital coverage under the Covenant Health Advantage Rx (HMO) plan includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both requiring prior authorization. For Inpatient Hospital-Acute, you pay a $325 copay for days 1-6, and a $0 copay for days 7-90. For Inpatient Hospital Psychiatric, you pay a $318 copay for days 1-5, and a $0 copay for days 6-90. Additional days, non-Medicare-covered stays, and upgrades for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $275 copay and 20% coinsurance, Observation Services with 20% coinsurance, Ambulatory Surgical Center (ASC) Services with a $250 copay, Outpatient Substance Abuse Services with a $45 copay for both individual and group sessions, and Outpatient Blood Services with 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered by the Covenant Health Advantage Rx (HMO) plan, but requires prior authorization. The copay for this benefit is $40.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Covenant Health Advantage Rx (HMO). Ground and air ambulance services have a $300 copay, and there is no coinsurance; however, 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 Covenant Health Advantage Rx (HMO) plan. Emergency Services have a copay of $120, while Urgently Needed Services have a copay of $50; both have no coinsurance. Worldwide Emergency Services have a maximum plan benefit coverage of $5,000.
Primary Care See details
The Covenant Health Advantage Rx (HMO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy with a $35 copay, physician specialist services with a $30 copay, mental health specialty services with a $30 copay for individual and group sessions, physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits, and psychiatric services with a $30 copay for individual and group sessions. Opioid treatment program services are covered with a $45 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include Medicare-covered services with no copay, annual physical exams, kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit, while other services like health education, in-home safety assessments, and more are not covered.
Hearing Services See details
Hearing services include hearing exams with a $40 copay, and prescription hearing aids with a plan-specified amount of $1000 every three years. Routine hearing exams and fitting/evaluation for hearing aids are covered once per year. Prescription hearing aids are covered, but Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $40 copay, eyewear with a combined maximum of $125 per year, contact lenses (12 pairs per year), eyeglasses (lenses and frames) (1 pair per year), eyeglass lenses (1 pair per year), and eyeglass frames (1 frame per year). Upgrades are not covered.
Dental Services See details
Dental services are covered, with a maximum plan benefit of $3,000 per year. Oral exams, dental x-rays, other diagnostic dental services, and prophylaxis (cleaning) are covered, with limitations on the number of visits and periodicity. Restorative services, endodontics, periodontics, prosthodontics (removable), and oral and maxillofacial surgery are covered with a 50% coinsurance, while prosthodontics (removable) has a coinsurance between 0% and 50%. Fluoride treatment, maxillofacial prosthetics, implant services, prosthodontics (fixed), and orthodontics are not covered.
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 Covenant Health Advantage Rx (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered by the Covenant Health Advantage Rx (HMO) plan. Durable Medical Equipment (DME) has a 20% coinsurance with no copay, while Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered; Prosthetic Devices and Medicare-covered Medical Supplies have a 20% coinsurance with no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Covenant Health Advantage Rx (HMO) plan. Diagnostic procedures and tests, as well as lab services, are not covered, while Diagnostic Radiological Services have a maximum copay of $325, and Therapeutic Radiological Services have a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the Covenant Health Advantage Rx (HMO) plan with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered. Services require authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but this plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Covenant Health Advantage Rx (HMO), but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered for SNF and non-Medicare-covered SNF stays are not covered.
Other Services See details
The Covenant Health Advantage Rx (HMO) plan covers over-the-counter (OTC) items with a maximum benefit coverage amount of $90.00 every three months; however, 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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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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