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Astiva Health C-SNP WOW – NorCal (HMO C-SNP)

H1993 - 013 - 0
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Astiva Health C-SNP WOW – NorCal (HMO C-SNP) is a Medicare Advantage Special Needs Plan by Astiva Health.

This page features plan details for 2025 Astiva Health C-SNP WOW – NorCal (HMO C-SNP) H1993 – 013 – 0 available in Counties: SCL.

Locations

Astiva Health C-SNP WOW – NorCal (HMO C-SNP) is offered in the following locations.

California
Santa Clara County, California

Click to see more locations

Plan Overview

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

Special Needs Plan Type:Chronic or Disabling Condition
Conditions Covered:CardiovascularDisorders, ChronicHeartFailure, DiabetesMellitus
Insurer:Astiva Health
Health Plan Deductible:$0
MOOP:$9,350 In-network
Drugs Covered:Yes

Ready to sign up for Astiva Health C-SNP WOW – NorCal (HMO C-SNP) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Astiva Health C-SNP WOW – NorCal (HMO C-SNP) has a monthly premium of $29.70. 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
$185.00 $0.00 $29.70 $ $
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 WOW – NorCal (HMO C-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $590.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

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 DLIS Full
$29.70$0.00

Initial Coverage Phase

After you pay your $590.00 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 $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Astiva Health C-SNP WOW – NorCal (HMO C-SNP) also provides the following benefits.

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

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – No Co pay (Limits Apply)
  • Endodontics
    • In-Network: No Coins – No Co pay (Limits Apply)
  • Implant Services
    • In-Network: No Coins – No Co pay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – No Co pay (Limits Apply)
  • Periodontics
    • In-Network: No Coins – No Co pay (Limits Apply)
  • Prosthodontics, fixed
    • In-Network: No Coins – No Co pay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: No Coins – No Co pay (Limits Apply)
  • Restorative Services
    • In-Network: No Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
  • Fluoride Treatment
    • In-Network: No Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – No Copay
  • Other Diagnostic Dental Services
    • In-Network: No Coins – No Copay
  • Other Preventive Dental Services
    • In-Network: No Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • 20% coinsurance (Authorization Required, Referral Required)
  • Lab services
    • $0 copay (Authorization Required, Referral Required)
  • Outpatient x-rays
    • 20% coinsurance (Authorization Required, Referral Required)
  • Diagnostic tests and procedures
    • 20% coinsurance (Authorization Required, Referral Required)

Doctor visits

  • Primary
    • $0 copay
  • Specialist
    • $0 copay (Authorization Required, Referral Required)

Emergency care/Urgent care

  • Urgent care
    • $0 copay
  • Emergency
    • $70 copay per visit (always covered)

Foot care (podiatry services)

  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • 20% coinsurance (Authorization Required, Referral Required)

Ground ambulance

    • $200 copay

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • $0 copay (Limits Apply, Authorization Required)
  • Hearing aids
    • $0 copay (Limits Apply, Authorization Required)
  • Medicare-Covered Hearing Exam
    • $0 copay (Authorization Required)
  • Hearing aids OTC
    • Not covered

Inpatient hospital coverage

    • Coming soon
      $816 per day for days 91 through 150 (Authorization Required, Referral Required)

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

    • $9,350 In-network

Medical equipment/supplies

  • 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)
  • Diabetes supplies
    • 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • 0-20% coinsurance (Authorization Required)

Mental health services

  • Outpatient individual therapy visit
    • $50 copay (Authorization Required, Referral Required)
  • Outpatient individual therapy visit with a psychiatrist
    • $45 copay (Authorization Required, Referral Required)
  • Inpatient hospital – psychiatric
    • Coming soon
      $816 per day for days 91 through 150 (Authorization Required, Referral Required)
  • Outpatient group therapy visit
    • $50 copay (Authorization Required, Referral Required)
  • Outpatient group therapy visit with a psychiatrist
    • $45 copay (Authorization Required, Referral Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • 20% coinsurance per visit (Authorization Required, Referral Required)

Preventive care

    • $0 copay

Rehabilitation services

  • Occupational therapy visit
    • 20% coinsurance (Authorization Required, Referral Required)
  • Physical therapy and speech and language therapy visit
    • 20% coinsurance (Authorization Required, Referral Required)

Skilled Nursing Facility

    • $0 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required, Referral Required)

Transportation

    • $0 copay (Limits Apply)

Vision

  • Eyeglass lenses
    • $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • $0 copay (Limits Apply)
  • Other
    • Not covered
  • Contact lenses
    • $0 copay (Limits Apply)
  • Eyeglass frames
    • $0 copay (Limits Apply)
  • Routine eye exam
    • $0 copay (Limits Apply, Authorization Required)
  • Upgrades
    • $0 copay (Limits Apply)

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

    • Covered

Ready to sign up for Astiva Health C-SNP WOW – NorCal (HMO C-SNP) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on Astiva Health C-SNP WOW – NorCal (HMO C-SNP)? See 2025 Astiva Health C-SNP WOW – NorCal (HMO C-SNP) at MedicareAdvantageRX.com.

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