Astiva Health Savings Plan (HMO)
H1993 - 001 - 0
(3 / 5)
Astiva Health Savings Plan (HMO) is a Medicare Advantage (Part C) Plan by Astiva Health.
This page features plan details for 2024 Astiva Health Savings Plan (HMO) H1993 – 001 – 0 available in Counties: OC, LA, RIV, SB, SD.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Astiva Health Savings Plan (HMO) is offered in the following locations.
Plan Overview
Astiva Health Savings Plan (HMO) offers the following coverage and cost-sharing.
| Insurer: | Astiva Health |
| Health Plan Deductible: | $0.00 |
| MOOP: | $2,500 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Astiva Health Savings Plan (HMO) ?
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Astiva Health Savings Plan (HMO) qualifies for a monthly Medicare Give Back Benefit of $164.90.
| Premium Reduction: | $164.90 |
Premium Breakdown
Astiva Health Savings Plan (HMO) has a monthly premium of $0.00. 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 |
|---|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $164.90 | $9.80 |
- 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 Savings Plan (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
| Additional 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 Full |
|---|---|
| $0.00 | $ |
NOTE: The Inflation Reduction Act of 2022 has expanded full subsidy eligibility under the LIS program to individuals with incomes up to 150% of the Federal Poverty Level. People who qualify for Extra Help generally will pay no more than $4.50 for each generic drug and $11.20 for each brand-name drug.
Initial Coverage Phase
After you pay your $0.00 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 $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $15.00 copay | $15.00 copay | ||
| 3 (Preferred Brand) | $45.00 copay | $45.00 copay | ||
| 4 (Non-Preferred Drug) | $98.00 copay | |||
| 5 (Specialty Tier) | 33% | |||
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $45.00 copay | $45.00 copay | ||
| 3 (Preferred Brand) | $135.00 copay | $135.00 copay | ||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay |
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00, you will pay no more than the amounts below for any drug tier until you reach $8,000.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $15.00 copay | $15.00 copay | ||
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | ||
| Generic drugs | ||||
| Brand-name drugs |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $45.00 copay | $45.00 copay | ||
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | ||
| Generic drugs | ||||
| Brand-name drugs |
| 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 $8,000.00, 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 Savings Plan (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $2,500 In-network |
| No |
| In-network | No |
| $75-200 copay per visit (Authorization is required.) (Referral is required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $0 copay (Authorization is required.) (Referral is required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $125 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $0 copay (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is required.) |
| Lab services | $0 copay (Authorization is required.) (Referral is required.) |
| Diagnostic radiology services (e.g., MRI) | $0-75 copay (Authorization is required.) (Referral is required.) |
| Outpatient x-rays | $0 copay (Authorization is required.) (Referral is required.) |
| Hearing exam | $10 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – inner ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – outer ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – over the ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Occupational therapy visit | $10 copay (Authorization is required.) (Referral is required.) |
| Physical therapy and speech and language therapy visit | $10 copay (Authorization is required.) (Referral is required.) |
| $150 copay (Not applicable.) (Not applicable.) |
| $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Foot exams and treatment | $10 copay (Authorization is required.) (Referral is required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is required.) (Referral is required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| $0 per day for days 1 through 10 $200 per day for days 11 through 22 $0 per day for days 23 through 90 (Authorization is required.) (Referral is required.) |
| Inpatient hospital – psychiatric | $0 per day for days 1 through 10 $200 per day for days 11 through 22 $0 per day for days 23 through 90 (Authorization is required.) (Referral is required.) |
| Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is required.) (Referral is required.) |
| Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is required.) (Referral is required.) |
| Outpatient group therapy visit | $25 copay (Authorization is required.) (Referral is required.) |
| Outpatient individual therapy visit | $25 copay (Authorization is required.) (Referral is required.) |
| $0 per day for days 1 through 20 $200 per day for days 21 through 100 (Authorization is required.) (Referral is required.) |
Ready to sign up for Astiva Health Savings Plan (HMO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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