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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.
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 |