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Covenant Health Advantage (HMO)

Texas Medicare Advantage Plan (2025 Plan)

Monthly Premium

Your Cost
$0
by Baylor Scott & White Health Plan

Additional Coverage

HearingVisionDental

Overall Government Star Rating

(coming soon)

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Plan Overview

Plan Name
Covenant Health Advantage (HMO)
Insurance Carrier
Baylor Scott & White Health Plan
Plan Type
Medicare Advantage Plan Without Prescription Drugs
Network Type
HMO

Covenant Health Advantage (HMO) is a Medicare Advantage Plan Without Prescription Drugs, which is available in Texas and offered by the health insurance company Baylor Scott & White Health Plan. This plan’s network type is HMO which determines in-network doctors who accept the health plan and whether a referral is needed.

Cost Summary

Monthly Premium
$0
Annual Deductible
$0
Max Out-of-Pocket
$5,600
Primary doctor visit
$0 copay
Specialist visit
$30 copay per visit
ER visit
$120 copay per visit (always covered)
Ambulance
$265 copay

Covenant Health Advantage (HMO) has a monthly premium cost of $0 per month, with an annual deductible of $0 and a maximum out of pocket cost sharing of $5,600 In-network. The most common benefit costs which people evaluate when choosing a plan are costs for a primary doctor visit, specialist doctor visit, emergency room visit, and ambulance. These costs are listed in this summary section and a full list of benefit costs for Covenant Health Advantage (HMO) are defined below.

Additional Benefits and Coverage

No
Part D Prescription Drug Coverage
Yes
Dental
Yes
Vision
Yes
Hearing

Covenant Health Advantage (HMO) is a Medicare Advantage plan which does not include Medicare Part D Prescription Drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. Covenant Health Advantage (HMO) includes coverage for hearing, vision, dental.

Medicare Advantage health plans can offer even more additional benefits. Covenant Health Advantage (HMO) includes coverage for the following additional benefits:

Other benefits

Fitness benefit
Not covered
Over the counter drug benefits
Limited coverage
In-home support services
Not covered
Home and bathroom safety devices
Not covered
Meals for short duration
Not covered
Annual physical exams
Limited coverage
Telehealth
Limited coverage

Plan Benefits and Coverage Details

Monthly Premium
$0
Health Portion of Premium
$0
Drug Portion of Premium
$0
Health Plan Deductible
$0
Health Plan Max Out-of-Pocket
$5,600 In-network
Nationwide Coverage included
No
Hearing Coverage included
Yes
Vision Coverage included
Yes
Dental Coverage included
Yes
Doctor Lookup Link
http://BSWHealthPlan.com/Medicare
Plan Link
http://BSWHealthPlan.com/Medicare

Medical Benefits

Doctor Services

Primary doctor visit
$0 copay
Specialist visit
$30 copay per visit

Tests, labs, & imaging

Diagnostic tests & procedures
$0 copay
Lab services
$0 copay
Diagnostic radiology services (like MRI)
$0-325 copay
Outpatient x-rays
$0 copay
Emergency care
$120 copay per visit (always covered)
Urgent care
$50 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage
$325 per day for days 1 through 6
$0 per day for days 7 through 90
Outpatient hospital coverage
$275 copay or 20% coinsurance per visit

Skilled nursing facility

Skilled nursing facility
$0 per day for days 1 through 20
$214 per day for days 21 through 100

Preventive services

Preventive services
$0 copay

Ambulance

Ground ambulance
$265 copay

Therapy services

Occupational therapy visit
$35 copay
Physical therapy & speech & language therapy visit
$35 copay

Mental health services

Outpatient group therapy with a psychiatrist
$30 copay
Outpatient individual therapy with a psychiatrist
$30 copay
Outpatient group therapy visit
$30 copay
Outpatient individual therapy visit
$30 copay

Opioid treatment services

Opioid treatment services
Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)
20% coinsurance per item
Prosthetics (like braces, artificial limbs)
20% coinsurance per item
Diabetes supplies
$0 copay

Prescription Drug Benefits

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

Part B Drugs

Chemotherapy drugs
0-20% coinsurance
Other Part B drugs
0-20% coinsurance

Extra Benefits

Hearing

Hearing exam
$40 copay
Fitting/evaluation
$0 copay
Hearing aids - All types
$0 copay

Preventive Dental

Oral exam
In-network: $0 copay
Out-of-network: $0 copay
Cleaning
In-network: $0 copay
Out-of-network: $0 copay
Fluoride treatment
Not covered
Dental x-rays
In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Restorative services
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Endodontics
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Periodontics
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Prosthodontics, removable
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Prosthodontics, fixed
Not covered
Maxillofacial prosthetics
Not covered
Implant services
Not covered
Oral and maxillofacial surgery
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Orthodontics
Not covered
Adjunctive general services
Not covered

Vision

Routine eye exam
$0 copay
Contact lenses
$0 copay
Eyeglasses (frames & lenses)
$0 copay
Eyeglass frames (only)
$0 copay
Eyeglass lenses (only)
$0 copay
Upgrades
Not covered

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