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Elite Health Plan Signature HMO
2027
Elite Health Plan Signature (HMO)
H6368-001
No premium, low maximum out-of-pocket limit, the Elite Health Signature HMO Plan is designed for members who may benefit from more comprehensive access to care and enhanced day-to-day support services, greater supplemental benefit flexibility, enhanced preventive services, and coordinated care management support.
Available in California in the following counties: Los Angeles, Riverside, San Bernardino.
Benefit information provided is a brief summary, not a complete description of benefits. For more information, contact The Plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1, of each year.
Monthly
Premium
$0.00
Primary Care & Specialist Care Visits
$0.00
Maximum Out-of-Pocket (MOOP)
$500.00
Type of care | What you'll pay |
|---|---|
Primary Care Office Visits | $0.00 |
Specialist Office Visits | $0.00 |
Inpatient Hospital Care | $0.00 |
Outpatient Hospital Services | $0.00 |
Ambulatory Surgical Center | $0.00 |
Urgent Care Services | $0.00 |
Emergency Care | $150.00 (waived if transferred to inpatient) |
Worldwide Coverage | $25,000.00 |
Prescription type | What you'll pay (30 day) |
|---|---|
Tier 1: Preferred Generic | $0.00 |
Tier 2: Generic | $0.00 |
Tier 3: Preferred Brand | $35.00 |
Tier 4: Non-Preferred Drugs | $98.00 |
Tier 5: Specialty Drugs | 33% |
Tier 6: Select Care Drugs | $0.00 |
Note: This chart only shows the cost for a one-month supply of medications. We also offer longer supplies as well as mail order for a 90-day supply on drug tiers 1, 2, 3, and 6. The evidence of coverage and our drug coverage page provide a much more detailed outline of the drug benefits and costs, including Insulin. Insulin costs are 25% of the cost of the drug or $15 for a one-month supply (whichever is less).
SUPPLEMENTAL | BENEFITS |
|---|---|
Dental | We provide a $2,000 allowance for dental care utilizing the Delta Dental PPO Medicare Advantage Network. Find out more about your dental benefit here. |
Groceries (special supplemental benefit for those with certain chronic conditions) | Groceries – if eligible through your providers validation SSBCI groceries are available to eligible enrollees. You may qualify for these benefits if you have been diagnosed with a chronic condition such as Diabetes, Cardiovascular Disease, Congestive Heart Failure (CHF), Mental Health Conditions, Cancer, or other qualifying conditions listed in your Evidence of Coverage. You must also meet all other eligibility criteria. Must be received through a “Nations Benefits” contracted provider or vendor. Members who qualify for SSBCI can use the Debit Card allowance to purchase healthy food and produce items. |
Fitness | Through the Nations Benefits Flexible Allowance, you can purchase a gym membership (not a personal trainer), memory or memory fitness programs or activity tracker. |
Flexible Benefit Allowance Debit Card | A $450 quarterly allowance (available for rollover until the 4th quarter) may be used for items and activities such as gym membership (not a personal trainer), memory or memory fitness programs, activity tracker, hearing test, prescription hearing aids (at a discount) with exam and fittings. The allowance also allows for the purchase of eligible OTC health and wellness products (including hearing aids) through the Plan’s OTC catalog and other Plan-approved purchasing channels. For those that qualify, groceries are also available through this allowance. |
Hearing | Through the Nation's Benefit Flexible Allowance debit card, you may use this (in addition to the other items allowed within the flexible allowance) to obtain a routine hearing test, prescription hearing aids (at a discount) with exam and fittings. The allowance also allows for the purchase of eligible OTC health and wellness products (including hearing aids) through the Plan’s OTC catalog and other Plan-approved purchasing channels. |
Over the Counter (OTC) | Through the flexible benefit allowance, you can purchase eligible OTC health and wellness products (including hearing aids) through Nations Benefits. You can shop in five ways: online, through a phone application, via phone, mail or in-store through numerous retailers. retailers such as Walmart, Walgreens, CVS, etc. Find out more about the OTC benefit here. |
Routine Acupuncture, Chiropractic and Massage Therapy | For each category, you will receive 12 visits per year for a $10 copay. This is offered through American Specialty Health (ASH). You canfind those providers in our directory. Find out more about these benefits here. |
Transportation | Through Nations Benefits, the plan offers 24 one-way rides for health related purposes. Contact members services 24 -72 hours in advance to assist with scheduling rides. Find out more about your transportation benefit here. |
Vision | Through the Nations Benefit Network of providers, we provide routine vision care including a test, lenses, frames or contracts. You will receive a $250.00 allowance for your routine vision benefit. Find out more about your vision benefit here. |
Worldwide Coverage | $25,000.00 allowance |
800-958-1129 (TTY: 711)
We are open M-F 8:00 a.m. – 8:00 p.m. PT.
Between 10/1 and 3/31, we are open 7 days a week, except for the major year-end holidays.
Elite Health Plan Signature HMO:
Coinsurance and Copays
Understanding Costs: With Elite Health Plan Signature HMO, you may have coinsurance and copays. Coinsurance is the percentage of the bill you pay, while copays are set amounts due at the time of service.
Quick Facts About Claims and More
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Claims Filing: Your provider and pharmacy will usually handle claim submissions for covered services or prescriptions. Once processed, you’ll receive a statement called an Explanation of Benefits (EOB) showing what was covered and your cost.
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What is an EOB? An EOB is not a bill—it’s a summary of services received, amounts paid, and any remaining balance.
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How to Use an EOB: Review your EOB carefully to ensure accuracy. If something doesn’t look right, contact Elite Health Plan Signature HMO Member Services for assistance.
Am I Covered?
It’s simple to find out what’s included with your plan. If you’re unsure:
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Review Your Evidence of Coverage (EOC): This document explains what’s covered, what you pay, and how the plan works. You’ll receive it by mail each year.
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Ask Member Services: Call the number listed on your ID card to speak with a representative who can walk you through your benefits.
Prescription Drug Coverage
Elite Health Plan Signature HMO includes coverage for many prescription drugs. Medications are grouped into tiers—brand-name drugs, generic drugs, and specialty drugs. Your share of the cost depends on the tier and plan rules such as prior authorization or step therapy.
Drug Formulary
The Drug Formulary is the official list of covered medications. It’s updated yearly and explains how each drug is covered. You and your doctor can use it to find the most affordable and effective treatment options. Access the latest formulary through the Find a Prescription tool.
Medication List
Keep a personal Medication List with your current prescriptions, directions, prescriber, and any known allergies. Bring it with you to doctor visits, hospitals, or emergency rooms, and share it with family or caregivers for safer care.