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.
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What is the
right plan for you?
Both plans are available in California, in Los Angeles, Riverside, and San Bernardino counties
Benefit information provided is a brief summary, not a complete description of benefits. For more information, contact Elite Health 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.
For more comprehensive information, please see the Evidence of Coverage.
You can also scroll to the bottom of the page to see the evidence of coverage and other important documents.
Type of care | Elite Health Plan Signature (HMO) | Elite Health Plan Core (HMO) |
|---|---|---|
Maximum Out-of-Pocket | $699.00 | $1,499.00 |
Primary Care Office Visits | $0.00 | $0.00 |
Specialist Office Visits | $0.00 | $0.00 |
Inpatient Hospital Care | $75.00 per day (1-5) | $100.00 per day (1-5) |
Outpatient Hospital Services | $0.00 | $0.00 |
Ambulatory Surgical Center | $0.00 | $0.00 |
Urgent Care Services | $0.00 | $0.00 |
Emergency Care | $95.00 (Waived if transferred to in-patient) | $150.00 (Waived if transferred to in-patient) |
PRESCRIPTION DRUGS | Elite Health Plan Signature (HMO) | Elite Health Plan Core (HMO) |
|---|---|---|
Tier 1: Preferred Generic | $0.00 | $0.00 |
Tier 2: Generic | $0.00 | $7.00 |
Tier 3: Preferred Brand | $35.00 | $47.00 |
Tier 4: Non-Preferred Drug | $98.00 | 25% |
Tier 5: Specialty Tier | 33% | 33% |
Tier 6: Select Care Drugs | $0.00 | $0.00 |
Insulin | Insulin is no more than 25% of the cost of the drug or $35 for a one-month supply. | Insulin is no more than 25% of the cost of the drug or $35 for a one-month supply. |
SUPPLEMENTAL BENEFIT | Elite Health Plan Signature (HMO) | Elite Health Plan Core (HMO) |
|---|---|---|
Routine Acupuncture, Chiropractic, Massage Therapy and Podiatry | 12 visits per year, $10 | 12 visits per year, $0 |
Dental | Included (Delta Dental) | Included (Delta Dental) |
Hearing | Included (Audicus) | Included (Audicus) |
Fitness | Online classes (Age Bold) | Online classes (Age Bold) |
Meals | 7 days, 2 meals per day, immediately post hospitalization | 7 days, 2 meals per day, immediately post hospitalization |
Over the Counter (OTC) | Your OTC benefit allows you to choose from products through our online catalog. You will receive $65 every quarter in OTC benefits. The $65 can not be rolled over to the next quarter. | Your OTC benefit allows you to choose from products through our online catalog. You will receive $90 every quarter in OTC benefits. The $90 can not be rolled over to the next quarter. |
Personal Emergency Response System (PERS) | PERS device, $0 | -- |
Transportation | 20 one-way trips | 10 one-way trips |
Worldwide Coverage | $10,000 allowance | $20,000 allowance |
Telehealth | Included | Included |
Vision | $250.00 allowance | $300.00 allowance |