Sentara Medicare Salute (HMO)
H2563 - 014 - 0
(3 / 5)
Sentara Medicare Salute (HMO) is a Medicare Advantage (Part C) Plan by Sentara Medicare.
This page features plan details for 2024 Sentara Medicare Salute (HMO) H2563 – 014 – 0 available in Virginia.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Sentara Medicare Salute (HMO) is offered in the following locations.
Plan Overview
Sentara Medicare Salute (HMO) offers the following coverage and cost-sharing.
| Insurer: | Sentara Medicare |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,400 In-network |
| Drugs Covered: | No |
Ready to sign up for Sentara Medicare Salute (HMO) ?
Premium Breakdown
Sentara Medicare Salute (HMO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $174.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Sentara Medicare Salute (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $3,400 In-network |
| No |
| In-network | No |
| $275 copay per visit (Authorization is required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $30 copay per visit (Authorization is required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $25 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0-85 copay (Authorization is required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $0-275 copay (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | $0-85 copay (Authorization is required.) (Referral is not required.) |
| Hearing exam | $25 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Office visit | $0.00 (Authorization is not required.) (Referral is not required.) |
| Oral exam | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | $50 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Restorative services | $50 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Endodontics | $50 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Periodontics | $50 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Extractions | $50 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $50 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not 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 | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | $30 copay (Authorization is required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $30 copay (Authorization is required.) (Referral is not required.) |
| $265 copay (Not applicable.) (Not applicable.) |
| $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Foot exams and treatment | $30 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | $30 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 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 copay per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is required.) (Referral is not 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 | $35 copay (Authorization is required.) (Not applicable.) |
| $275 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $275 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $30 copay (Authorization is required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $30 copay (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit | $30 copay (Authorization is required.) (Referral is not required.) |
| Outpatient individual therapy visit | $30 copay (Authorization is required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
Ready to sign up for Sentara Medicare Salute (HMO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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