Fitness Benefit
Physical Fitness
Cost not publishedMandatory
IncludedAstiva Health Savings Plan - NorCal (HMO)
Astiva Health
HMOSanta Clara CountyIncludes Part DPlan year 2026
$0/momonthly premiumplus $165/mo back on your Part B premium
$3,000most you pay in-network per year
3.5overall CMS star rating
861members enrolled, January 2026
Plan-level limits
Premium, deductibles, and the most you can pay out of pocket in a year.
In-network out-of-pocket maximum$3,000
Part B premium giveback, per month$165
Plan premium, per month$0
What a year on this plan would likely cost
What you pay for care
In-network costs for every service in this plan's CMS benefit filing. A copay is a fixed dollar amount; coinsurance is a percentage of the bill.
Hospital stays
Inpatient psychiatric stay
Days 1–5$125 per day
Days 6–15$200 per day
Days 16–90$0 per day
Doctor visits
Chiropractic care (Medicare-covered)
$15
Copay
Podiatry (Medicare-covered)
$15
Copay
Emergency and urgent care
Emergency room visit
$90
Copay
Emergency care outside the U.S.
Up to $50,000
Allowance
Mental health and substance use
Individual therapy session
$25
Copay
Group therapy session
$25
Copay
Opioid treatment program
$25
Copay
Partial hospitalization program
$80
Copay
Referral required
Prior authorization required
Therapy and rehabilitation
Occupational therapy
$25
Copay
Physical and speech therapy
$25
Copay
Cardiac rehabilitation
$15
Copay
Intensive cardiac rehabilitation
$15
Copay
Pulmonary rehabilitation
$15
Copay
Supervised exercise therapy for peripheral artery disease
$15
Copay
Tests, labs and imaging
Diagnostic radiology (MRI, CT, PET)
$0–$50
Copay, depends on the service
Therapeutic radiology
20%
Coinsurance — your share of the bill
Outpatient hospital and surgery
Ambulatory surgical center
$100
Copay
Ambulance
Ground ambulance
$160
Copay
Air ambulance
20%
Coinsurance — your share of the bill
Medical equipment and supplies
Durable medical equipment
0–20%
Coinsurance, depends on the service
Medical supplies
20%
Coinsurance — your share of the bill
Prosthetic devices
20%
Coinsurance — your share of the bill
Dialysis
Dialysis
20%
Coinsurance — your share of the bill
Part B drugs
Part B drugs
0–20%
Coinsurance, depends on the service
Chemotherapy drugs
0–20%
Coinsurance, depends on the service
Part B insulin
0–20%
Coinsurance, depends on the service
Never more than $35 for a one-month supply
Vision
Eyewear allowance
Up to $125 every two years
Allowance
Extra benefits beyond Original Medicare
Supplemental benefits this plan filed with CMS, with the cap and period exactly as filed.
Not offered by this plan
Health EducationIn-Home Safety AssessmentPersonal Emergency Response System (PERS)Medical Nutrition Therapy (MNT)Post discharge In-Home Medication ReconciliationRe-admission PreventionWigs for Hair Loss Related to ChemotherapyWeight Management ProgramsAlternative TherapiesTherapeutic MassageAdult Day Health ServicesNutritional/Dietary BenefitHome-Based Palliative CareIn-Home Support ServicesSupport for Caregivers of EnrolleesAdditional Sessions of Smoking and Tobacco Cessation CounselingEnhanced Disease ManagementTelemonitoring ServicesRemote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)Home and Bathroom Safety Devices and ModificationsCounseling Services
Dental
$250 every three months allowance, shared by preventive and comprehensive services. No dental deductible.
Preventive
Oral examsMandatory, prior authorization
CleaningsMandatory, prior authorization
X-raysMandatory, prior authorization
Fluoride treatmentMandatory, prior authorization
Other diagnostic servicesMandatory, prior authorization
Other preventive servicesMandatory, prior authorization
Comprehensive
Restorative (fillings)Mandatory, prior authorization
Endodontics (root canals)Mandatory, prior authorization
Periodontics (gum treatment)Mandatory, prior authorization
Oral surgeryMandatory, prior authorization
Fixed prosthodontics (crowns, bridges)Mandatory, prior authorization
Removable prosthodontics (dentures)Mandatory, prior authorization
Adjunctive general servicesMandatory, prior authorization
Prescription drugs (Part D)
$0 annual drug deductible · 6 formulary tiers · mail order available. Costs shown for a 30-day supply.
Initial coverage
| Tier | Preferred retail | Standard retail | Mail order | Insulin | Deductible |
|---|---|---|---|---|---|
| 1. Preferred Generic | — | No copay | — | — | Waived |
| 2. Generic | — | No copay | — | — | Waived |
| 3. Preferred Brand | — | $40 copay | — | — | Waived |
| 4. Non-Preferred Drug | — | $95 copay | — | — | Waived |
| 5. Specialty Tier specialty | — | 33% coinsurance | — | — | Waived |
| 6. Select Care Drugs | — | No copay | — | — | Waived |
Catastrophic (after the out-of-pocket threshold)
| Tier | Preferred retail | Standard retail | Mail order | Insulin | Deductible |
|---|---|---|---|---|---|
| 1. Preferred Generic | No copay | No copay | No copay | — | Waived |
| 2. Generic | No copay | No copay | No copay | — | Waived |
| 3. Preferred Brand | No copay | No copay | No copay | — | Waived |
| 4. Non-Preferred Drug | No copay | No copay | No copay | — | Waived |
| 5. Specialty Tier specialty | No copay | No copay | No copay | — | Waived |
| 6. Select Care Drugs | No copay | No copay | No copay | — | Waived |
Out-of-pocket threshold for the catastrophic phase: $2,100.
Is my medicine on this plan’s list?
Pharmacies near you in this plan's network
From the plan's filed Part D pharmacy network, matched to geocoded pharmacy locations. Preferred pharmacies come first: they carry the lower copay column in the tier table above. The ZIP you enter stays in this browser.
CMS star ratings
Star ratings are set by CMS for the whole contract, so every plan under this contract shares them.
3.5 out of 5Overall rating
4 out of 5Health services (Part C)
3.5 out of 5Drug plan (Part D)
Staying healthy: screenings, tests and vaccines
4- Annual flu vaccine5
- Breast cancer screening2
- Colorectal cancer screening3
- Monitoring physical activity5
- Improving or maintaining mental health3
- Improving or maintaining physical health5
Managing chronic (long-term) conditions
3- Readmissions4
- Kidney health4
- Blood pressure4
- Statin therapy3
- Pain assessment3
- Bladder control5
- Medication review3
- Diabetes eye exam4
- Transitions of care1
- Diabetes blood sugar3
- Followup after emergency department visit2
- Medication reconciliation2
- Special needs plan SNP care management1
Member experience with the health plan
4- Customer service5
- Care coordination5
- Healthcare quality3
- Health plan rating4
- Getting needed care5
Member complaints and changes in the plan's performance
4- Complaints4
- Members leaving4
- Quality improvement4
Health plan customer service
- Call center3
Drug plan customer service
3- Call center foreign language interpreter and TTY availability3
Drug plan complaints and changes
4- Complaints4
- Members leaving4
- Quality improvement3
Member experience with the drug plan
5- Drug plan rating5
- Prescription drugs4
Drug safety and accuracy of drug pricing
4- Price accuracy5
- Statin diabetes5
- Medication therapy management comprehensive medication review completion3
- Medication adherence for diabetes medications4
- Medication adherence for hypertension RAS antagonists s3
- Medication adherence for cholesterol statins2
Service area and network
Sold in 1 California county.
Santa Clara
Doctor directory
12,821 providers are named in Astiva Health’s directory for this plan, dated Jul 31, 2026.
A doctor named there is listed. A doctor missing from it is unknown, never out of network: carrier directories are partial and change monthly.
Contract with Medicare sinceJan 1, 2021
Medicare Advantage regionCalifornia
Ask about this plan
A question box grounded in this plan's filed benefits, drug list, and pharmacy network. It reads the same records shown on this page and says so when something is not filed.
Answers come from this plan’s filed benefits, drug list, and pharmacy network. They are not enrollment advice; the Evidence of Coverage is the final word.