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Astiva Health C-SNP Premium (HMO C-SNP)

H1993 - 008 - 0
4 out of 5 stars (4 / 5)

Astiva Health C-SNP Premium (HMO C-SNP) is a Medicare Advantage (Part C) Special Needs Plan by Astiva Health.

This page features plan details for 2023 Astiva Health C-SNP Premium (HMO C-SNP) H1993 – 008 – 0 available in San Diego and Orange County.

IMPORTANT: This page features the 2023 version of this plan. See the 2024 version using the link below:
2024 Astiva Health C-SNP WOW (HMO C-SNP) H1993 - 008 - 0

Locations

Astiva Health C-SNP Premium (HMO C-SNP) is offered in the following locations.

California
Orange County, California
San Diego County, California

Click to see more locations

Plan Overview

Astiva Health C-SNP Premium (HMO C-SNP) offers the following coverage and cost-sharing.

Special Needs Plan Type:Chronic or Disabling Condition
Conditions Covered:
  • Cardiovascular Disorders
  • Chronic Heart Failure
  • Diabetes Mellitus
    • Insurer:Astiva Health
    Health Plan Deductible:$0.00
    MOOP:$8,000 In-network
    Drugs Covered:Yes
    Please Note:
    • This plan does not charge an annual deductible for all drugs. The $505 annual deductible only applies to drugs on certain tiers.

    Ready to sign up for Astiva Health C-SNP Premium (HMO C-SNP) ?

    Get help from a licensed insurance agent.

    Call 1-877-354-4611 TTY 711.

    8am – 11pm EST. 7 days a week

    Premium Breakdown

    Astiva Health C-SNP Premium (HMO C-SNP) has a monthly premium of $38.90. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
    Part B Part C Part D Part B Give Back Total
    $164.90 $0.00 $38.90 $0.00 $203.80
    Please Note:
    • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
    • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

    Drug Info

    Astiva Health C-SNP Premium (HMO C-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

    Drug Deductible: $505.00
    Initial Coverage Limit: $4,660.00
    Catastrophic Coverage Limit: $7,400.00
    Drug Benefit Type: Enhanced
    Gap Coverage: Yes
    Formulary Link: Formulary Link

    Part D Premium Reduction

    The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.
    Part D LIS 25% LIS 50% LIS 75% LIS Full
    $38.90 $43.40 $34.80 $26.30 $17.70

    Initial Coverage Phase

    After you pay your $505.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.

    Gap Coverage Phase

    After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.

    Tier Cost
    All other tiers (Generic)25%
    All other tiers (Brand-name)25%

    Catastrophic Coverage Phase

    After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.

    Drug TypeCost Share
    Generic drugs$4.15 copay or 5% (whichever costs more)
    Brand-name drugs$10.35 copay or 5% (whichever costs more)

    Additional Benefits

    Astiva Health C-SNP Premium (HMO C-SNP) also provides the following benefits.

    Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    In-Network: No

    Dental (comprehensive)

    Diagnostic services: $0 copay (no limits) (authorization required) (referral required)
    Endodontics: $25-720 copay (no limits) (authorization required) (referral required)
    Extractions: $40-380 copay (no limits) (authorization required) (referral required)
    Non-routine services: $0 copay (no limits) (authorization required) (referral required)
    Periodontics: $40-780 copay (no limits) (authorization required) (referral required)
    Prosthodontics, other oral/maxillofacial surgery, other services: $0-600 copay (no limits) (authorization required) (referral required)
    Restorative services: $25-400 copay (no limits) (authorization required) (referral required)

    Dental (preventive)

    Cleaning: $0-95 copay (limits may apply) (authorization not required) (referral not required)
    Dental x-ray(s): $0 copay (limits may apply) (authorization not required) (referral not required)
    Fluoride treatment: $0 copay (limits may apply) (authorization not required) (referral not required)
    Oral exam: $0 copay (limits may apply) (authorization not required) (referral not required)

    Diagnostic procedures/lab services/imaging

    Diagnostic radiology services (e.g., MRI): 0-20% coinsurance (authorization required) (referral required)
    Diagnostic tests and procedures: $0 copay (authorization required) (referral required)
    Lab services: $0 copay (authorization required) (referral required)
    Outpatient x-rays: $0 copay (authorization required) (referral required)

    Doctor visits

    Primary: $0 copay
    Specialist: $0 copay (authorization required) (referral required)

    Emergency care/Urgent care

    Emergency: $95 copay per visit (always covered)
    Urgent care: $0 copay

    Foot care (podiatry services)

    Foot exams and treatment: $0 copay (authorization required) (referral required)
    Routine foot care: $0 copay (limits may apply) (authorization required) (referral required)

    Ground ambulance

    $50 copay

    Health plan deductible

    $0.00

    Health plan deductibles (other)

    In-Network: No

    Hearing

    Fitting/evaluation: $0 copay (limits may apply) (authorization not required) (referral not required)
    Hearing aids: $0 copay (limits may apply) (authorization required) (referral required)
    Hearing exam: $0 copay (authorization not required) (referral not required)

    Hospital coverage (inpatient)

    $250 per day for days 1 through 7
    $75 per day for days 8 through 30
    $0 per day for days 31 through 90 (authorization required) (referral required)

    Hospital coverage (outpatient)

    20% coinsurance per visit (authorization required) (referral required)

    Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    $8,000 In-network

    Medical equipment/supplies

    Diabetes supplies: 0-20% coinsurance per item (authorization required)
    Durable medical equipment (e.g., wheelchairs, oxygen): 0-20% coinsurance per item (authorization required)
    Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required)

    Medicare Part B drugs

    Chemotherapy: 20% coinsurance (authorization required)
    Other Part B drugs: 20% coinsurance (authorization required)

    Mental health services

    Inpatient hospital – psychiatric: $150 per day for days 1 through 5
    $0 per day for days 6 through 90 (authorization required) (referral required)
    Outpatient group therapy visit: $0 copay (authorization required) (referral required)
    Outpatient group therapy visit with a psychiatrist: $25 copay (authorization required) (referral required)
    Outpatient individual therapy visit: $0 copay (authorization required) (referral required)
    Outpatient individual therapy visit with a psychiatrist: $25 copay (authorization required) (referral required)

    Optional supplemental benefits

    No

    Preventive care

    $0 copay (authorization not required) (referral not required)

    Rehabilitation services

    Occupational therapy visit: $0 copay (authorization required) (referral required)
    Physical therapy and speech and language therapy visit: $0 copay (authorization required) (referral required)

    Skilled Nursing Facility

    $0 per day for days 1 through 20
    $185 per day for days 21 through 100 (authorization required) (referral required)

    Transportation

    $0 copay (limits may apply) (authorization required) (referral required)

    Vision

    Contact lenses: $0 copay (limits may apply) (authorization not required) (referral not required)
    Eyeglass frames: $0 copay (limits may apply) (authorization not required) (referral not required)
    Eyeglass lenses: $0 copay (limits may apply) (authorization not required) (referral not required)
    Eyeglasses (frames and lenses): $0 copay (limits may apply) (authorization not required) (referral not required)
    Other: Not covered (no limits)
    Routine eye exam: $0 copay (limits may apply) (authorization required) (referral required)
    Upgrades: $0 copay (limits may apply) (authorization not required) (referral not required)

    Wellness programs (e.g., fitness, nursing hotline)

    Covered (authorization not required) (referral not required)

    Ready to sign up for Astiva Health C-SNP Premium (HMO C-SNP) ?

    Get help from a licensed insurance agent.

    Call 1-877-354-4611 TTY 711.

    8am – 11pm EST. 7 days a week

    Table of Contents

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