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. You can enroll beginning 10/15/2025.
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Elite Health Plan Signature HMO
Elite Health Plan Signature (HMO)
H6368-001
With no premium, low maximum out-of-pocket, and reduced costs for care, this plan is ideal for individuals who may require extra support on a more regular basis. Supplemental benefits and worldwide coverage are provided.
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)
$699.00
For more comprehensive benefit information, please see our Evidence of Coverage in the Plan Documents section.
TYPE OF CARE | What you'll pay |
|---|---|
Primary Care Office Visits | $0.00 |
Specialist Office Visits | $0.00 |
Inpatient Hospital Care | $75.00 per day (1-5) |
Outpatient Hospital Services | $0.00 |
Ambulatory Surgical Center | $0.00 |
Urgent Care Services | $0.00 |
Emergency Care | $95.00 (Waived if transferred to in-patient) |
PRESCRIPTION TYPE | What you'll pay (one-month) |
|---|---|
Tier 1: Preferred Generic | $0.00 |
Tier 2: Generic | $0.00 |
Tier 3: Preferred Brand | $35.00 |
Tier 4: Non-Preferred Drug | $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 $35 for a one-month supply (whichever is less).
Supplemental Benefits | Benefit Details |
|---|---|
Dental | We've partnered with Delta Dental to provide dental coverage. Find out more here. |
Vision | We've partnered with United Vision Plan to provide your glasses and/or contacts. Just go to an in-network provider to obtain your prescription and “try-on” and order online with a $250.00 allowance. Find out more here. |
Hearing | Elite Health Plan’s hearing benefit through Audicus includes hearing aids for a copayment. Do your hearing test from home. Go to your Summary of Benefits or Evidence of Coverage for details. Find out more here. |
Meals | Meals will be provided for up to 7 days, 2 meals per day immediately following surgery or inpatient hospitalization on an unlimited basis throughout the year at no cost to you. Prior Authorization is required. Find more here. |
Fitness | Your plan’s fitness benefit includes on-demand classes online classes, and is offered through Age Bold. Find out more here. |
Transportation | Elite Health Plan Signature Plan offers 20 one-way transportation annually through Uber Health. Contact Member Services 24 to 48 hours in advance to assist with scheduling rides. Find out more here. |
Routine Acupuncture, Chiropractic, Massage Therapy and Podiatry | For each category, you will receive 12 visits per year for a $10 copay. This is offered through American Specialty Health (ASH). You can find those providers in our directory. Find out more here. |
Over the Counter (OTC) | Your OTC benefit allows you to choose from products through our online catalog. You will receive a $65 a quarter in OTC benefits. The $65 can not be rolled over to the next quarter. Find out more here. |
Personal Emergency Response System (PERS) | Elite Health Plan Signature Plan is offering at PERS device at no cost sharing to you through Medical Guardian. Prior Authorization is required. Find out more here. |
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.