Sentara Medicare Savings (HMO)   Print

H2563-019 | Hampton Roads - Southside/Peninsula

Sentara Medicare Savings is a Medicare Advantage plan that reduces the Part B premium deducted from a member’s Social Security (SSA) check each month by $70. This plan combines medical and prescription drug coverage with a full range of extra benefits and services for a $0 monthly premium.

With Sentara Medicare Savings, you will have access to a diverse network of high-quality doctors and specialty providers to help manage your healthcare needs. Enjoy the flexibility of a covered virtual visit from a computer or smartphone 24/7.

Highlights

  • $70 per month back in your SSA check
  • $0 or low PCP and specialist copays
  • Prescription drug coverage
  • Over-the-counter product allowance
  • Dental, vision, and hearing allowances
  • SilverSneakers®
  • Transportation - medical
  • 100-day, $0 prescription home delivery
  • Meals after hospitalization
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Plan Details

  • Premium

     

    $0.00
    a month

Medical Coverage

  • Medical Maximum Out-of-Pocket

    This is the most you pay for copays, coinsurance, and other costs for Medicare-covered medical services for the year. Once you reach this limit, you will not have to pay any out-of-pocket costs for the rest of the year.
    This does not include Part D prescription drugs.

    $3400.00
    per year

  • Primary Care Doctor

    each visit

    $5.00
    copay

  • Specialist

    each visit

    $35.00
    copay

  • Emergency Care

    each visit
    If you are admitted to the hospital within 24 hours, you do not have to pay your cost share for emergency care.

    $120.00
    copay

  • Urgent Care

    each visit
    If you are admitted to the hospital within 24 hours, you do not have to pay your cost share for emergency care.

    $10.00
    copay

  • Lab

    Applies to Medicare-covered lab services. Cost-sharing for other services may apply.

    $0.00
    copay

  • X-Ray

    For Medicare-covered outpatient X-rays. Cost-sharing for other services may apply.

    $0.00
    copay at PCP office

    $85.00
    copay at all other locations

  • Diagnostic Tests and Procedures

    Prior authorization required for Medicare-covered diagnostic radiological services except ultrasound.

    $0.00
    copay at PCP office

    $85.00
    copay at all other locations

  • Advanced Diagnostic Imaging Procedures

    (e.g., MRI, MRA, CT, CTA, PET scans, etc.)

    $285.00
    copay

  • Therapeutic Radiological Services

     

    $35.00
    copay at Specialist office

    20%
    coinsurance at all other locations

  • Inpatient Hospital Care

    $300.00
    per day, Days 1-6

    $0.00
    per day, Days 7-90

  • Inpatient Psychiatric Hospital Care

    $300.00
    per day, Days 1-6

    $0.00
    per day, Days 7-90

  • Partial Hospitalization

    $35.00
    copay

  • Outpatient Hospital Care

    $275.00
    copay

  • Outpatient Group or Individual Therapy with a Psychiatrist

    $35.00
    copay for group sessions

    $35.00
    copay for individual sessions

  • Outpatient Group or Individual Therapy with a Licensed Clinical Psychologist or Licensed Clinical Social Worker

    Prior authorization required for electroconvulsive therapy (ECT) and intensive outpatient program (IOP)

    $35.00
    copay for group sessions

    $35.00
    copay for individual sessions

  • Skilled Nursing Facility

    Coverage for up to 100 days.
    No prior hospital stay is required.

    $0.00
    per day, Days 1-20

    $203.00
    per day, Days 21-100

  • Physical Therapy

    $35.00
    copay

  • Ambulance

    Prior authorization required for elective ambulance transport.

    $285.00
    copay

  • Medical Transportation

    Limit of 12 one-way trips for health related services per year at no cost within plan service area.

    $0.00
    copay

    12 one-way trips
    per year

  • Medicare Part B Drugs

    0%-20%
    coinsurance

  • Annual Physical Exam

    $0.00
    copay

  • Chiropractic, Routine

    $20.00
    copay

    12 visits
    per year

  • Fitness Benefit

     

    Fitness center membership, including fitness classes, through SilverSneakers®.

  • Foot Care (Routine Podiatry)

    $35.00
    copay

    8 visits
    Every Year

  • Over-the-Counter

    On the first day every three months (each quarter) (January, April, July, October), members will receive their allowance to use to purchase OTC items. These can be ordered from the catalog by phone, mail, or online. Amount does not carry forward.

    $50.00
    Every Three Months

  • Personal Emergency Response System

    A Personal Emergency Response System (PERS) connects eligible members to help with just a push of a button. Eligible members receive a PERS in-home monitoring device that can get them help quickly, 24 hours a day. Eligible members must have a working landline and/or cellular phone coverage to take part in this benefit. Prior authorization is required.

    $0.00
    copay

  • Bathroom Safety Devices

    Members may obtain up to two bathroom safety devices in a calendar year.

    $0.00
    copay

  • Virtual Visits

    Appointments via secure phone or video using your computer or smart phone with a local doctor board certified in internal medicine, family practice, emergency medicine, or pediatrics. These doctors can diagnose, treat, and write prescriptions for routine medical conditions. Appointments are available 24 hours a day/7 days a week/365 days a year.

    $0.00
    copay

  • MDLive Behavioral Health Virtual Visits

    Appointments via secure phone or video using your computer or smart phone with a counselor or psychiatrist. MDLive psychiatrists can send prescriptions to your local, participating pharmacy. Appointments are available 24 hours a day/7 days a week/365 days a year.

    $0.00
    copay

  • Hearing Benefits

     

    • $35.00
      copay

    • every 12 months

      $0.00
      copay

    • 3 per 36 months

      $0.00
      copay

    • every 12 months

      $0.00
      copay

  • Vision Benefits

     
    •  

      $0.00
      copay

    • $0.00
      copay

    •  

      $0.00
      copay

    •  

      $0.00
      copay

  • Comprehensive
    Dental Coverage

     
    •  

      $2000.00
      per year

    • (amalgam and resin)

      $30.00
      copay

    •  

      $30.00
      copay

    •  

      $30.00
      copay

Prescription Coverage

  • Yearly Deductible Stage

     

    During this stage, Sentara Medicare pays its share of the cost of your Tiers 1 (Preferred Generic), 2 (Non-Preferred Generic) and 3 (Preferred Brand) drugs and you pay (or others on your behalf) pay your share of the cost. You pay the full cost of your Tiers 4 (Non-Preferred Brand) and 5 (Specialty) drugs. You stay in this stage for your Tiers 4 and 5 drugs until you have paid the $150 yearly deductible for these drugs.

  • Initial Coverage Limit

     

    During this stage, Sentara Medicare pays its share of the cost of your Tiers 1- 5 drugs and you (or others on your behalf) pay your share of the cost.

    You pay the costs outlined in the charts on the next page until your year-to-date "total drug costs" (your payments plus any Part D plan's payments) reach $5,030.

  • Coverage Gap

     

    After the total yearly drug cost (including what our plan has paid and what you have paid) reaches $5,030, you enter the coverage gap (also called the "donut hole"). During this stage you (or others on your behalf) pay 25% of the price of generic and brand name drugs (plus a portion of the dispensing fee).

    You stay in this stage until the amount of your year - to - date "out-of-pocket costs" reaches $8,000.Not everyone will enter the coverage gap.

  • Catastrophic Coverage

     

    After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000, your plan will pay the full cost for the remainder of the year.

  • In Network Standard Pharmacy

    30 day supply
    • Preferred generic drugs

      $5.00
      copay

    • Generic drugs

      $15.00
      copay

    • Preferred brand drugs

      $47.00
      copay

    • Non-preferred drugs

      $100.00
      copay

    • Specialty drugs

      30%
      coinsurance

  • In Network Standard Pharmacy

    90 day supply (Tier 1 drugs covered at up to 100-day supply)
    • Preferred generic drugs

      $12.50
      copay

    • Generic drugs

      $37.50
      copay

    • Preferred brand drugs

      $117.50
      copay

    • Non-preferred drugs

      $300.00
      copay

  • In Network Preferred Pharmacy

    30 day supply
    • Preferred generic drugs

      $0.00
      copay

    • Generic drugs

      $10.00
      copay

    • Preferred brand drugs

      $42.00
      copay

    • Non-preferred drugs

      $95.00
      copay

    • Specialty drugs

      30%
      coinsurance

  • In Network Preferred Pharmacy

    90 day supply (Tier 1 drugs covered at up to 100-day supply)
    • Preferred generic drugs

      $0.00
      copay

    • Generic drugs

      $25.00
      copay

    • Preferred brand drugs

      $105.00
      copay

    • Non-preferred drugs

      $285.00
      copay

  • Out of Network Pharmacy

    30 day supply
    • Preferred generic drugs

      $5.00
      copay

    • Generic drugs

      $15.00
      copay

    • Preferred brand drugs

      $47.00
      copay

    • Non-preferred drugs

      $100.00
      copay

    • Specialty drugs

      30%
      copay

  • Mail Order

    90 day supply (Tier 1 drugs covered at up to 100-day supply)
    • Preferred generic drugs

      $0.00
      copay

    • Generic drugs

      $0.00
      copay

    • Preferred brand drugs

      $84.00
      copay

    • Non-preferred drugs

      $285.00
      copay

  • Long Term Care Pharmacy

    30 day supply
    • Preferred generic drugs

      $0.00
      copay

    • Generic drugs

      $10.00
      copay

    • Preferred brand drugs

      $42.00
      copay

    • Non-preferred drugs

      $95.00
      copay

    • Specialty drugs

      30%
      copay

Sentara Medicare Savings (HMO)

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Plan Documents