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What is the
right plan for you?
2027 Benefits
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.
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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) - 001 | Elite Health Plan Core (HMO) - 002 |
|---|---|---|
Maximum Out-of-Pocket | $500.00 | $2,400.00 |
Primary Care Office Visits | $0.00 | $0.00 |
Specialist Office Visits | $0.00 | $0.00 |
Inpatient Hospital Care | $0.00 | $150.00 per day (4-15) |
Outpatient Hospital Services | $0.00 | $125.00 |
Ambulatory Surgical Center | $0.00 | $0.00 |
Urgent Care Services | $0.00 | $0.00 |
Emergency Care | $150.00 (Waived if transferred to in-patient) | $150.00 (Waived if transferred to in-patient) |
Type of care | Elite Health Plan Signature (HMO) - 001 | Elite Health Plan Core (HMO) - 002 |
|---|---|---|
Tier 1: Preferred Generic | $0.00 | $0.00 |
Tier 2: Generic | $0.00 | $10.00 |
Tier 3: Preferred Brand | $35.00 | $47.00 |
Tier 4: Non-Preferred Drug | $98.00 | 25% |
Tier 5: Specialty Tier | 33% | 31% |
Tier 6: Select Care Drugs | $0.00 | $0.00 |
For insulin costs, please see the information on the plan page or in the EOC.
SUPPLEMENTAL BENEFIT | Elite Health Plan Signature (HMO) - 001 | Elite Health Plan Core (HMO) - 002 |
|---|---|---|
Acupuncture, Chiropractic, Massage (Routine) | 12 visits per year, $10 | 12 visits per year, $0 |
Dental (Routine) | $2,000 / Year Allowance (through Delta Dental PPO Medicare Advantage Network) | $600 / Year Allowance (through Delta Dental PPO Medicare Advantage Network) |
Flexible Allowance - Debit Card (includes groceries for those who qualify for SSBCI) | $450 / Quarter (rollover) good through 12/31/2027 or upon disenrollment. | $75 / Quarter (rollover) good through 12/31/2027 or upon disenrollment. |
Groceries | See flexible allowance. Only if you qualify for the SSBCI. | See flexible allowance. Only if you qualify for the SSBCI. |
Fitness | See Flexible Allowance | See Flexible Allowance |
Hearing (Routine) | See Flexible Allowance | See Flexible Allowance |
Over-the-counter (OTC) | See Flexible Allowance | See Flexible Allowance |
Telehealth | Included if provided by your provider | Included if provided by your provider |
Transportation | 24 one-way trips for health services | 12 one-way trips for health services |
Vision (Routine) | Routine Vision - $250 annual allowance | Routine Vision - $100 annual allowance |
Worldwide Coverage | $25,000 allowance | $10,000 allowance |