Central Health Classic Care Plan IV (HMO)

3 out of 5 stars
$0.00
Monthly Premium

Central Health Classic Care Plan IV (HMO) is a HMO plan offered by Molina Healthcare, Inc.,

Plan ID: H5649-018

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.

Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.

Learn more about Medicare Advantage plans such as Central Health Classic Care Plan IV (HMO) - H5649-018 by Molina Healthcare, Inc., as well as other Medicare Advantage plans available in your area.

$0.00
Monthly Premium

California Counties Served

San FranciscoSan Mateo

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $100
Out of Pocket Max In-Network: $2499
Out-of-Network: N/A
Initial Coverage Limit $0
Catastrophic Coverage Limit $2100
Primary Care Doctor Visit

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty Doctor Visit


Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $10
Prior Authorization Required for Doctor Specialty Visit
Referral Required for Doctor Specialty Visit
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$200 per day for days 1 to 6
$0 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services
Urgent Care

Urgent Care:
Copayment for Urgent Care $0

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $150
Maximum Plan Benefit of $50,000

Emergency Room Visit

Emergency Care:
Copayment for Emergency Care $150
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $150
Copayment for Worldwide Emergency Transportation $150
Maximum Plan Benefit of $50,000

Ambulance Transportation

Ground Ambulance:
Copayment for Ground Ambulance Services $0 to $250
Minimum copayment for transfer from OON hospital to an INN hospital. Maximum copayment for all other ambulance services.

Air Ambulance:
Coinsurance for Air Ambulance Services $20%
Prior Authorization Required for Air Ambulance

Health Care Services and Medical Supplies

Central Health Classic Care Plan IV (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0
Copayment for Routine Care $0

  • Maximum 30 Routine Care every year

Prior Authorization Required for Chiropractic Services
Referral Required for Chiropractic Services
Diabetes Supplies, Training, Nutrition Therapy and Monitoring

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0
Prior authorization may be required. Prior authorization is not required for preferred manufacturer.
Durable Medical Equipment (DME)

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20%
Prior Authorization Required for Durable Medical Equipment
0% Coinsurance: Canes, Commodes, Crutches, Walkers, Attachments20% Coinsurance: All Other Medicare-covered DME
Prior authorization may be required. Prior authorization is not required for preferred manufacturers.
Diagnostic Tests, Lab and Radiology Services, and X-Rays


Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Referral Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $200
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0
Prior Authorization Required for Outpatient Diag/Therapeutic Rad ServicesReferral Required for Outpatient Diag/Therapeutic Rad Services
Home Health Care

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Referral Required for Home Health Services
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$225 per day for days 1 to 6
$0 per day for days 7 to 90
Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services
Mental Health Outpatient Care

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $25
Copayment for Medicare-covered Group Sessions $25
Prior authorization required for outpatient mental health care. Referral required for outpatient mental health care.
Outpatient Services / Surgery

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $250
Prior Authorization Required for Outpatient Hospital Services
Referral Required for Outpatient Hospital Services
Minimum amount for diagnostic colonoscopies in an outpatient setting. Maximum amount for all other services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $250
Prior Authorization Required for Outpatient Observation Services
Referral Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $150
Prior Authorization Required for Ambulatory Surgical Center Services
Referral Required for Ambulatory Surgical Center Services
Minimum amount for diagnostic colonoscopies in an ASC setting. Maximum amount for all other services.
Outpatient Substance Abuse Care

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $10
Copayment for Medicare-covered Group Sessions $10
Prior Authorization Required for Outpatient Substance Abuse Services
Referral Required for Outpatient Substance Abuse Services
Over-the-counter (OTC) Items

$120 combined allowance every 3 months for OTC items. OTC benefit includes access to OTC hearing aids and herbal products through catalog purchase only.

Unused allowance does not carry over to the next month.

Please see the Flexible Extras section for a complete list of benefit and services that are included in the combined allowance.
Podiatry Services

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $25
Prior Authorization Required for Podiatry Services
Referral Required for Podiatry Services
Skilled Nursing Facility Care

Skilled Nursing Facility Services:
Copayment for Skilled Nursing Facility Services per Stay $0
Prior Authorization Required for Skilled Nursing Facility Services
Referral Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care

Medicare Covered Preventive Dental:
Copayment for Office Visit $0
Prior Authorization Required for Medicare Covered Preventive Dental

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
Copayment for Oral exams $0

  • Maximum 2 visits every year

Copayment for Dental x-rays $0

  • Maximum 2 visits every year

Copayment for Other diagnostic services $0 to $6
Copayment for Prophylaxis $0

  • Maximum 2 visits every year

Copayment for Fluoride treatment $0

  • Maximum 2 visits every year

Copayment for Other preventive services $0 to $20

Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
Copayment for Restorative services $25 to $400
Copayment for Endodontics $25 to $720
Copayment for Periodontics $0 to $780
Copayment for Prothodontics, removable $0 to $600
Copayment for Implant services $45 to $2160
Copayment for Prothodontics, fixed $0 to $840
Copayment for Maxillofacial surgery $0 to $380
Copayment for Adjunctive general services $0 to $300

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits


Eye Exams:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Eye Exams $0

  • Maximum 1 Routine Eye Exams every year

Prior Authorization Required for Eye Exams
Referral Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0
Copayment for Eyeglasses (lenses and frames) $0

  • Maximum 1 Pair every year

Copayment for Eyeglass Lenses $0

  • Maximum 1 Pair every year

Copayment for Eyeglass Frames $0

  • Maximum 1 Pair every year

Copayment for Upgrades $0
Maximum Plan Benefit of $200 every year
Referral Required for Eyewear

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits

Hearing Exams:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Hearing Exams $0

  • Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0

  • Maximum 1 visit every year


Hearing Aids:
Copayment for Hearing Aids $575 to $2099

  • Maximum 2 Hearing Aids every year

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs

$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

  • COVID-19 shots

  • Flu shots

  • Hepatitis B shots

  • Pneumococcal shots

Tobacco use cessation
Yearly "Wellness" visit

Prescription Drug Costs and Coverage

The Central Health Classic Care Plan IV (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $100 (excludes Tiers 1, 2 and 6) per year.

Coverage Cost
Coverage & Cost
Annual Drug Deductible $100 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Standard retail $0.00
  • Standard mail order $0.00
Generic
  • Standard retail $2.00
  • Standard mail order $2.00
Select Care Drugs
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $100 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Standard retail $0.00
  • Standard mail order $0.00
Generic
  • Standard retail $4.00
  • Standard mail order $4.00
Select Care Drugs
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $100 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Standard retail $0.00
  • Standard mail order $0.00
Generic
  • Standard retail $4.00
  • Standard mail order $4.00
Select Care Drugs
  • Standard retail $0.00
  • Standard mail order $0.00
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