2025 Sonder HMO/PPO Plans

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Benefits you want. Plans you need.

We know what you need is unique to you. Sonder Health Plans offers four plans to fit your health and lifestyle.

Explore our plans to find the right fit for you! You can see more details about each plan on the Summary of Benefits.

$0 Premiums on All Plans

$0 Copay on Your PCP Visits

$0 Copay on Specialist Visits

when you become a Sonder member

24/7 Nurse Hotline Access

Vision, Hearing and Dental Benefits in Every Plan

$0 Premiums on All Plans

$0 Copay on Your PCP Visits

$0 Copay on Specialist Visits

when you become a Sonder Diabetes Wellness member

24/7 Nurse Hotline Access

Vision, Hearing and Dental Benefits in Every Plan

Sonder HMO/PPO Plan Details

Click on icons below to view and compare plan details.

HMO – H1748015
Sonder
Complete Health Advantage

HMO – H1748015

Sonder Complete Health Advantage

Medicare Advantage Part D Plan

Unless indicated, benefits are per service or per year.
*Only for members who have qualifying chronic medical conditions.
Please see Summary of Benefits for full list of conditions.

Deductible & Max Out-Of-Pocket

Deductible	$0
MOOP	$2,950

Part A

Inpatient Acute	$200 days 1-5;$0 days 6-90
Inpatient Psych	$200 days 1-5;$0 days 6-90
SNF	$0 days 1-20;$184 days 21-100
Home Health	$0

Part B

Cardiac & Pulmonary Rehab	$20 Cardiac/Pulm/SET for PAD, $40 Intensive Cardiac Rehab
PT/OT/ST	$10.00
ER	$125.00
Urgent Care	$10.00
PCP	$0.00
Chiro	$10.00
Specialist	$0.00
Mental Health	$10.00
Podiatry	$10.00
Other Health Care Professional	$0 to $40 ($0 copay at office $40 copay at facility)
Psychiatry	$10.00
Outpatient Lab	$0.00
X-Rays	$0 to $100
Diagnostic Radiology	$0 For office based diagnostic imaging, $150 for facility based diagnostic imaging (e.g., sonagrams, ultrasounds) – $300 for advanced imaging (e.g., CT, MRI, PET)
Therapeutic Radiology	20%
Outpatient Hospital Services	$250.00
Outpatient Hospital Observation	$350.00
ASC	$150.00
Outpatient Substance Abuse	$25 Ind / $15 Group
Ambulance – Ground	$300.00
Ambulance – Air	$750.00
DME	20%
Prosthetics	20%
Medical Supplies	20%
Diabetic Supplies	$0.00
Therapeutic Shoes or Inserts	0%
Renal Dialysis	20%
Chemotherapy Drugs	20%
Part B Drugs	20%

Part D

Deductible	$0
ICL	$2,000
Tier 1 Retail 30/Retail 90/Mail	$0/$0/$0
Tier 2 Retail 30/Retail 90/Mail	$10/$30/$0
Tier 3 Retail 30/Retail 90/Mail	$44/$132/$88
Tier 4 Retail 30/Retail 90/Mail	$95/$285/$285
Tier 5 Retail 30/Retail 90/Mail	33%/33%/33%
Tier 2 Insulin	$10/$30/$0
Tier 3 Insulin	$35/$70/$70
Tier 4 Insulin	$35/$70/$70

Supplemental Benefits

Worldwide Emergency	Up to $50,000 Maximum
Non-Emergency Transportation	50 one-way trips
OTC	$200 per quarter
Meals	2 meals a day for 14 days provided immediately following each surgery or inpatient hospitalization. Up to 2 times per year
Fitness	Silver & Fit
Nursing Hotline	Covered

SSBCI
Flex Card $230 / Month to apply towards list below (amount does NOT roll over):
-Gas Card
-Home Safety/Access Modifications
-Social and Active Club Membership (includes out of network gym)
-Internet / Cell Data
-Pet Supplies

Members also get:
$105 /month Grocery Card

Other (SSBCI Not required)
In Home Support – $0 4 hour per day, up to max 104 hours per year (including home safety and modifications, caregiver, social support and medication reconciliation)
Caregiver Training
Personal Emergency Response System
Platelet Rich Plasma – 6 visits / year

Dental
Dental – Preventative
Annual Max Benefit Amount: $3000 combined with Comprehensive
Exams: 1 every 6 months
Prophylaxis: 1 every 6 months
Flouride: 1 every year
Dental – Comprehensive
Annual Max Benefit Amount: $3000 combined with Preventative
Non-Routine Services: Unlimited
Diagnostic Services: Unlimited
Restorative Services: Unlimited
Endodontics: Unlimited
Periodontics: Unlimited
Extractions: Unlimited
Prosthodontics, Other Oral/Maxillofacial Surgery: Unlimited

Vision
Vision – Exams:
Medicare Covered – $40, 1 Routine Exam / year – $0
Vision – Hardware:
Annual Max Benefit Amount: $400
Contact Lenses
Eyeglasses (lenses and frames)

Hearing
Hearing – Exams	Medicare Covered – $40, 1 Routine Exam / year – $0
Hearing – Aids	$699 or $999 copay per hearing aid, depeding on device

HMO – H1748016
Sonder
Vitality Matters

HMO – H1748016

Sonder Vitality Matters

A Plan For active seniors

Additional Plan Benefits

Unless indicated, benefits are per service or per year.
*Only for members who have qualifying chronic medical conditions.
Please see Summary of Benefits for full list of conditions.

Deductible & Max Out-Of-Pocket

Deductible	$0
MOOP	$3,950

Part A

Inpatient Acute	$350 days 1-5;$0 days 6-90
Inpatient Psych	$350 days 1-5;$0 days 6-90
SNF	$0 days 1-20;$184 days 21-100
Home Health	$10

Part B

Cardiac & Pulmonary Rehab	$25 Cardiac/Pulm, $20 SET for PAD, $40 Intensive Cardiac Rehab
PT/OT/ST	$25.00
ER	$125.00
Urgent Care	$30.00
PCP	$0.00
Chiro	$15.00
Specialist	$0.00
Mental Health	$40.00
Podiatry	$40.00
Other Health Care Professional	$40.00
Psychiatry	$40.00
Outpatient Lab	$0.00
X-Rays	$0 to $100
Diagnostic Radiology	$0 For office based diagnostic imaging, $150 for facility based diagnostic imaging (e.g., sonagrams, ultrasounds) – $300 for advanced imaging (e.g., CT, MRI, PET)
Therapeutic Radiology	20%
Outpatient Hospital Services	$0 – $280 ($0 for Orthopedic Procedures)
Outpatient Hospital Observation	$350.00
ASC	$0 – $180 ($0 for Orthopedic Procedures)
Outpatient Substance Abuse	$25 Ind / $15 Group
Ambulance – Ground	$225.00
Ambulance – Air	$750.00
DME	20%
Prosthetics	20%
Medical Supplies	20%
Diabetic Supplies	20%
Therapeutic Shoes or Inserts	20%
Renal Dialysis	20%
Chemotherapy Drugs	20%
Part B Drugs	20%

Part D

Deductible	$0
ICL	$2,000
Tier 1 Retail 30/Retail 90/Mail	$0/$0/$0
Tier 2 Retail 30/Retail 90/Mail	$10/$30/$0
Tier 3 Retail 30/Retail 90/Mail	$44/$132/$88
Tier 4 Retail 30/Retail 90/Mail	$95/$285/$285
Tier 5 Retail 30/Retail 90/Mail	33%/33%/33%
Tier 2 Insulin	$10/$30/$0
Tier 3 Insulin	$35/$70/$70
Tier 4 Insulin	$35/$70/$70

Supplemental Benefits

Worldwide Emergency	Up to $50,000 Maximum
Non-Emergency Transportation	50 one-way trips
OTC	$125 per quarter
Meals	2 meals a day for 14 days provided immediately following each surgery or inpatient hospitalization. Up to 2 times per year
Fitness	Silver & Fit
Nursing Hotline	Covered

SSBCI
Flex Card $250 / Month to apply towards list below (amount does NOT roll over):
-Gas Card
-Home Safety/Access Modifications
-Social and Active Club Membership (includes out of network gym and wellness centers)
-Internet / Cell Data
-Pet Supplies
-Salon Care – Hair, Manicure, etc…

Members also get:
$90 Grocery Card
$40/month towards weight loss program of your choice

Other (SSBCI Not required)
Flex: $100/month – Stamina/Yoga/Exercise program
Routine foot care $0 – 6 visit per year
Routine Chiro – $0 Copay 12 visits per year
Dental, Vision, Hearing Flex Card: $500
Platelet Rich Plasma – 6 visits / year
Additional excluded drug coverage (generic Viagra, generic Cialis, generic Levitra, generic Bromfed DM and generic Propecia)
Nutritional Dietary Needs up to 6 sessions per year

Dental
Dental – Preventative
Annual Max Benefit Amount: $2000 combined with Comprehensive
Exams: 1 every 6 months
Prophylaxis: 1 every 6 months
Flouride: 1 every 6 months
X-Rays: 1 every 2 years
Dental – Comprehensive
Annual Max Benefit Amount: $2000 combined with Preventative
Non-Routine Services: Unlimited
Diagnostic Services: Unlimited
Restorative Services: Unlimited
Endodontics: Unlimited
Periodontics: Unlimited
Extractions: Unlimited
Prosthodontics, Other Oral/Maxillofacial Surgery: Unlimited

Vision
Vision – Exams:
Medicare Covered – $30, 1 Routine Exam / year – $0
Vision – Hardware:
Annual Max Benefit Amount: $200
Contact Lenses
Eyeglasses (lenses and frames)

Hearing
Hearing – Exams	Medicare Covered – $30, 1 Routine Exam / year – $0
Hearing – Aids	$699 or $999 copay per hearing aid, depeding on device

C-SNP – H1748010
Sonder
My Choice Medicare Advantage

HMO – H1748010

Sonder My Choice

Medicare Advantage Plans with Part D Prescription Drug Coverage

Additional Plan Benefits

Choose one benefit from each of the choice benefits below

Unless indicated, benefits are per service or per year.
*Only for members who have qualifying chronic medical conditions.
Please see Summary of Benefits for full list of conditions.

Deductible & Max Out-Of-Pocket

Deductible	$0
MOOP	$6,700

Part A

Inpatient Acute	$350 days 1-6;$0 days 7-90
Inpatient Psych	$350 days 1-6;$0 days 7-90
SNF	$0 days 1-20;$203 days 21-100
Home Health	$0

Part B

Cardiac & Pulmonary Rehab	$30 Cardiac/Pulm, $25 SET for PAD, $50 Intensive Cardiac Rehab
PT/OT/ST	$45.00
ER	$125.00
Urgent Care	$30.00
PCP	$0.00
Chiro	$20.00
Specialist	$0.00
Mental Health	$40.00
Podiatry	$40.00
Other Health Care Professional	$0 to $40 ($0 copay at office $40 copay at facility)
Psychiatry	$40.00
Outpatient Lab	$0.00
X-Rays	$0 to $100
Diagnostic Radiology	$0 For office based diagnostic imaging, $150 for facility based diagnostic imaging (e.g., sonagrams, ultrasounds) – $300 for advanced imaging (e.g., CT, MRI, PET)
Therapeutic Radiology	20%
Outpatient Hospital Services	$300.00
Outpatient Hospital Observation	$350.00
ASC	$150.00
Outpatient Substance Abuse	$25 Ind / $15 Group
Ambulance – Ground	$325.00
Ambulance – Air	$750.00
DME	20%
Prosthetics	20%
Medical Supplies	20%
Diabetic Supplies	20%
Therapeutic Shoes or Inserts	20%
Renal Dialysis	20%
Chemotherapy Drugs	20%
Part B Drugs	20%

Part D

Deductible	$0
ICL	$2,000
Tier 1 Retail 30/Retail 90/Mail	$0/$0/$0
Tier 2 Retail 30/Retail 90/Mail	$10/$30/$0
Tier 3 Retail 30/Retail 90/Mail	$44/$132/$88
Tier 4 Retail 30/Retail 90/Mail	$95/$285/$285
Tier 5 Retail 30/Retail 90/Mail	33%/33%/33%
Tier 2 Insulin	$10/$30/$0
Tier 3 Insulin	$35/$70/$70
Tier 4 Insulin	$35/$70/$70

Supplemental Benefits

Worldwide Emergency	Up to $10,000 Maximum
Non-Emergency Transportation	12 one-way trips
OTC	$200 per quarter
Meals	2 meals a day for 14 days provided immediately following each surgery or inpatient hospitalization. Up to 2 times per year
Fitness	Silver & Fit
Nursing Hotline	Covered

SSBCI
Member Selects one item from the list below:
-$400 Per Month Grocery Card
-$325 Per Month Gas Card
-$3,500 Medical Reconstructive Procedures
-$3,000 Mobility Device Allowance
All members receive:
-12 one way trips for non-primarily medical transporation

Other (SSBCI Not required)
Member Selects one item from the list below:
-$4,000 Comprehensive Dental
-$3,500 Comprehensive Vision Services (including procedures)
-$3,000 Hearing Aid Allowance
All members receive:
-In Home Support – $0 4 hour per day, up to max 104 hours per year (including home safety assessment, caregiver, social support and medication reconciliation)
-Platelet Rich Plasma – 6 visits / year

Other Tier (SSBCI Not required)
Member selects one item from the list below:
-Routine Acupuncture – 12 Visits
-Routine Chiro – 12 Visits

Dental
Dental Preventative
Exams: 1 every 6 months
Prophylaxis: 1 every 6 months
Flouride: 1 every 6 months
X-Rays: 1 every 2 years

Vision
Vision – Exams	Medicare Covered – $40, 1 Routine Exam / year – $0
Vision – Hardware	Medicare Covered Only $40

Hearing
Hearing – Exams	Medicare Covered – $40
Hearing – Aids	Not Covered

PPO – H4618-001
Sonder
Access Plus

PPO – H4618-001

Sonder Access Plus

Expanded Access To Out-of-Network Providers

$0 Deductible
$0 Premium
$0 PCP
$20 Specialist
$0 Home Health
$205 Flex Card per Month*
$80 Grocery Card per Month*

For Out of Network services, you generally pay 40% – 50% coinsurance. See Summary of Benefits for more details.
*Only for members who have qualifying chronic medical conditions. Please see Summary of Benefits for full list of conditions.

Deductible & Max Out-Of-Pocket

	IN NETWORK	OUT OF NETWORK
Deductible	$0	$0
MOOP	$5,500	$10,000 (Combined)

Part A

	IN NETWORK	OUT OF NETWORK
Inpatient Acute	$300 days 1-5;$0 days 6-60	40% Coinsurance
Inpatient Psych	$350 days 1-5;$0 days 6-60	40% Coinsurance
SNF	$0 days 1-20;$184 days 21-100	$0 days 1-20;$184 days 21-100
Home Health	$0	40% Coinsurance

Part B

	IN NETWORK	OUT OF NETWORK
Cardiac & Pulmonary Rehab	$20 Cardiac/Pulm/SET for PAD, $40 Intensive Cardiac Rehab	40% Coinsurance
PT/OT/ST	$10.00	40% Coinsurance
ER	$125.00	$125.00
Urgent Care	$10.00	$10.00
PCP	$0.00	40% Coinsurance
Chiro	$10.00	40% Coinsurance
Specialist	$20.00	40% Coinsurance
Mental Health	$10.00	40% Coinsurance
Podiatry	$10.00	40% Coinsurance
Other Health Care Professional	$0 to $40 ($0 copay at office $40 copay at facility)	40% Coinsurance
Psychiatry	$10.00	40% Coinsurance
Outpatient Lab	$0.00	40% Coinsurance
X-Rays	$0 to $100	40% Coinsurance
Diagnostic Radiology	20% coinsurance for diagnostic imaging (e.g., sonagrams, ultrasounds) – and for advanced imaging (e.g., CT, MRI, PET)	40% Coinsurance
Therapeutic Radiology	20%	40% Coinsurance
Outpatient Hospital Services	$250.00	40% Coinsurance
Outpatient Hospital Observation	$300.00	40% Coinsurance
ASC	$150.00	20% Coinsurance
Outpatient Substance Abuse	$25 Ind / $15 Group	40% Coinsurance
Ambulance – Ground	$300.00	$300.00
Ambulance – Air	$450.00	$450.00
DME	20%	40% Coinsurance
Prosthetics	20%	40% Coinsurance
Medical Supplies	20%	40% Coinsurance
Diabetic Supplies	20%	40% Coinsurance
Therapeutic Shoes or Inserts	20%	40% Coinsurance
Renal Dialysis	20%	40% Coinsurance
Chemotherapy Drugs	20%	40% Coinsurance
Part B Drugs	20%	40% Coinsurance

Part D

	IN NETWORK	OUT OF NETWORK
Deductible	$0	NA
ICL	$2,000	NA
Tier 1 Retail 30/Retail 90/Mail	$0/$0/$0	NA
Tier 2 Retail 30/Retail 90/Mail	$10/$30/$0	NA
Tier 3 Retail 30/Retail 90/Mail	$44/$132/$88	NA
Tier 4 Retail 30/Retail 90/Mail	$95/$285/$285	NA
Tier 5 Retail 30/Retail 90/Mail	33%/33%/33%	NA
Tier 2 Insulin	$10/$30/$0	NA
Tier 3 Insulin	$35/$70/$70	NA
Tier 4 Insulin	$35/$70/$70	NA

Supplemental Benefits

	IN NETWORK	OUT OF NETWORK
Worldwide Emergency	Up to $50,000 Maximum	Up to $50,000 Maximum
Non-Emergency Transportation	50 one-way trips	NA
OTC	$200 per quarter	NA
Meals	2 meals a day for 14 days provided immediately following each surgery or inpatient hospitalization. Up to 2 times per year	NA
Fitness	Silver & Fit	NA
Nursing Hotline	Covered	50% Coinsurance

SSBCI
IN NETWORK
Flex Card $205 / Month to apply towards list below (amount does NOT roll over):
-Gas Card
-Home Safety/Access Modifications
-Social and Active Club Membership
-Internet / Cell Data
Members also get:
$80 /month Grocery Card

OUT OF NETWORK
NA

Other (SSBCI Not required)
IN NETWORK Personal Emergency Response System $500 Flex Card (Dental, Vision and Hearing)
OUT OF NETWORK NA

Dental
IN NETWORK
Dental – Preventative Annual Max Benefit Amount: $2200 combined with Comprehensive Exams: 1 every 6 months Prophylaxis: 1 every 6 months Flouride: 1 every year X-Rays: 1 every 2 years
Dental – Comprehensive Annual Max Benefit Amount: $2200 combined with Preventative Non-Routine Services: Unlimited Diagnostic Services: Unlimited Restorative Services: Unlimited Endodontics: Unlimited Periodontics: Unlimited Extractions: Unlimited Prosthodontics, Other Oral/Maxillofacial Surgery: Unlimited
OUT OF NETWORK
Dental – Preventative 50% Coinsurance
Dental – Comprehensive 50% Coinsurance

Vision
IN NETWORK
Vision – Exams: Medicare Covered – $40, 1 Routine Exam / year – $0
Vision – Hardware: Annual Max Benefit Amount: $400 Contact Lenses Eyeglasses (lenses and frames)
OUT OF NETWORK
Vision – Exams: 50% Coinsurance
Vision – Hardware: 50% Coinsurance

Hearing
IN NETWORK
Hearing – Exams:	Medicare Covered – $40, 1 Routine Exam / year – $0
Hearing – Aids:	$699 or $999 copay per hearing aid, depending on device
OUT OF NETWORK
Hearing – Exams:	50% Coinsurance
Hearing – Aids:	50% Coinsurance, hearing aid up to $2,000

HMO – H1748015
Sonder
Complete Health Advantage
HMO – H1748010
Sonder
My Choice Medicare Advantage
PPO – H4618-001
Sonder
Access Plus
HMO – H1748016
Sonder
Vitality Matters

HMO – H1748015

Sonder Complete Health Advantage

Medicare Advantage Part D Plan

Unless indicated, benefits are per service or per year.
*Only for members who have qualifying chronic medical conditions.
Please see Summary of Benefits for full list of conditions.

Deductible & Max Out-Of-Pocket

Deductible	$0
MOOP	$2,950

Part A

Inpatient Acute	$200 days 1-5;$0 days 6-90
Inpatient Psych	$200 days 1-5;$0 days 6-90
SNF	$0 days 1-20;$184 days 21-100
Home Health	$0

Part B

Cardiac & Pulmonary Rehab	$20 Cardiac/Pulm/SET for PAD, $40 Intensive Cardiac Rehab
PT/OT/ST	$10.00
ER	$125.00
Urgent Care	$10.00
PCP	$0.00
Chiro	$10.00
Specialist	$0.00
Mental Health	$10.00
Podiatry	$10.00
Other Health Care Professional	$0 to $40 ($0 copay at office $40 copay at facility)
Psychiatry	$10.00
Outpatient Lab	$0.00
X-Rays	$0 to $100
Diagnostic Radiology	$0 For office based diagnostic imaging, $150 for facility based diagnostic imaging (e.g., sonagrams, ultrasounds) – $300 for advanced imaging (e.g., CT, MRI, PET)
Therapeutic Radiology	20%
Outpatient Hospital Services	$250.00
Outpatient Hospital Observation	$350.00
ASC	$150.00
Outpatient Substance Abuse	$25 Ind / $15 Group
Ambulance – Ground	$300.00
Ambulance – Air	$750.00
DME	20%
Prosthetics	20%
Medical Supplies	20%
Diabetic Supplies	$0.00
Therapeutic Shoes or Inserts	0%
Renal Dialysis	20%
Chemotherapy Drugs	20%
Part B Drugs	20%

Part D

Deductible	$0
ICL	$2,000
Tier 1 Retail 30/Retail 90/Mail	$0/$0/$0
Tier 2 Retail 30/Retail 90/Mail	$10/$30/$0
Tier 3 Retail 30/Retail 90/Mail	$44/$132/$88
Tier 4 Retail 30/Retail 90/Mail	$95/$285/$285
Tier 5 Retail 30/Retail 90/Mail	33%/33%/33%
Tier 2 Insulin	$10/$30/$0
Tier 3 Insulin	$35/$70/$70
Tier 4 Insulin	$35/$70/$70

Supplemental Benefits

Worldwide Emergency	Up to $50,000 Maximum
Non-Emergency Transportation	50 one-way trips
OTC	$200 per quarter
Meals	2 meals a day for 14 days provided immediately following each surgery or inpatient hospitalization. Up to 2 times per year
Fitness	Silver & Fit
Nursing Hotline	Covered

SSBCI
Flex Card $230 / Month to apply towards list below (amount does NOT roll over):
-Gas Card
-Home Safety/Access Modifications
-Social and Active Club Membership (includes out of network gym)
-Internet / Cell Data
-Pet Supplies

Members also get:
$105 /month Grocery Card

Other (SSBCI Not required)
In Home Support – $0 4 hour per day, up to max 104 hours per year (including home safety and modifications, caregiver, social support and medication reconciliation)
Caregiver Training
Personal Emergency Response System
Platelet Rich Plasma – 6 visits / year

Dental
Dental – Preventative
Annual Max Benefit Amount: $3000 combined with Comprehensive
Exams: 1 every 6 months
Prophylaxis: 1 every 6 months
Flouride: 1 every year
Dental – Comprehensive
Annual Max Benefit Amount: $3000 combined with Preventative
Non-Routine Services: Unlimited
Diagnostic Services: Unlimited
Restorative Services: Unlimited
Endodontics: Unlimited
Periodontics: Unlimited
Extractions: Unlimited
Prosthodontics, Other Oral/Maxillofacial Surgery: Unlimited

Vision
Vision – Exams:
Medicare Covered – $40, 1 Routine Exam / year – $0
Vision – Hardware:
Annual Max Benefit Amount: $400
Contact Lenses
Eyeglasses (lenses and frames)

Hearing
Hearing – Exams	Medicare Covered – $40, 1 Routine Exam / year – $0
Hearing – Aids	$699 or $999 copay per hearing aid, depeding on device

HMO – H1748010

Sonder My Choice

Medicare Advantage Plans with Part D Prescription Drug Coverage

Additional Plan Benefits

Choose one benefit from each of the choice benefits below

Unless indicated, benefits are per service or per year.
*Only for members who have qualifying chronic medical conditions.
Please see Summary of Benefits for full list of conditions.

Deductible & Max Out-Of-Pocket

Deductible	$0
MOOP	$6,700

Part A

Inpatient Acute	$350 days 1-6;$0 days 7-90
Inpatient Psych	$350 days 1-6;$0 days 7-90
SNF	$0 days 1-20;$203 days 21-100
Home Health	$0

Part B

Cardiac & Pulmonary Rehab	$30 Cardiac/Pulm, $25 SET for PAD, $50 Intensive Cardiac Rehab
PT/OT/ST	$45.00
ER	$125.00
Urgent Care	$30.00
PCP	$0.00
Chiro	$20.00
Specialist	$0.00
Mental Health	$40.00
Podiatry	$40.00
Other Health Care Professional	$0 to $40 ($0 copay at office $40 copay at facility)
Psychiatry	$40.00
Outpatient Lab	$0.00
X-Rays	$0 to $100
Diagnostic Radiology	$0 For office based diagnostic imaging, $150 for facility based diagnostic imaging (e.g., sonagrams, ultrasounds) – $300 for advanced imaging (e.g., CT, MRI, PET)
Therapeutic Radiology	20%
Outpatient Hospital Services	$300.00
Outpatient Hospital Observation	$350.00
ASC	$150.00
Outpatient Substance Abuse	$25 Ind / $15 Group
Ambulance – Ground	$325.00
Ambulance – Air	$750.00
DME	20%
Prosthetics	20%
Medical Supplies	20%
Diabetic Supplies	20%
Therapeutic Shoes or Inserts	20%
Renal Dialysis	20%
Chemotherapy Drugs	20%
Part B Drugs	20%

Part D

Deductible	$0
ICL	$2,000
Tier 1 Retail 30/Retail 90/Mail	$0/$0/$0
Tier 2 Retail 30/Retail 90/Mail	$10/$30/$0
Tier 3 Retail 30/Retail 90/Mail	$44/$132/$88
Tier 4 Retail 30/Retail 90/Mail	$95/$285/$285
Tier 5 Retail 30/Retail 90/Mail	33%/33%/33%
Tier 2 Insulin	$10/$30/$0
Tier 3 Insulin	$35/$70/$70
Tier 4 Insulin	$35/$70/$70

Supplemental Benefits

Worldwide Emergency	Up to $10,000 Maximum
Non-Emergency Transportation	12 one-way trips
OTC	$200 per quarter
Meals	2 meals a day for 14 days provided immediately following each surgery or inpatient hospitalization. Up to 2 times per year
Fitness	Silver & Fit
Nursing Hotline	Covered

SSBCI
Member Selects one item from the list below:
-$400 Per Month Grocery Card
-$325 Per Month Gas Card
-$3,500 Medical Reconstructive Procedures
-$3,000 Mobility Device Allowance
All members receive:
-12 one way trips for non-primarily medical transporation

Other (SSBCI Not required)
Member Selects one item from the list below:
-$4,000 Comprehensive Dental
-$3,500 Comprehensive Vision Services (including procedures)
-$3,000 Hearing Aid Allowance
All members receive:
-In Home Support – $0 4 hour per day, up to max 104 hours per year (including home safety assessment, caregiver, social support and medication reconciliation)
-Platelet Rich Plasma – 6 visits / year

Other Tier (SSBCI Not required)
Member selects one item from the list below:
-Routine Acupuncture – 12 Visits
-Routine Chiro – 12 Visits

Dental
Dental Preventative
Exams: 1 every 6 months
Prophylaxis: 1 every 6 months
Flouride: 1 every 6 months
X-Rays: 1 every 2 years

Vision
Vision – Exams	Medicare Covered – $40, 1 Routine Exam / year – $0
Vision – Hardware	Medicare Covered Only $40

Hearing
Hearing – Exams	Medicare Covered – $40
Hearing – Aids	Not Covered

PPO – H4618-001

Sonder Access Plus

Expanded Access To Out-of-Network Providers

$0 Deductible
$0 Premium
$0 PCP
$20 Specialist
$0 Home Health
$205 Flex Card per Month*
$80 Grocery Card per Month*

Deductible & Max Out-Of-Pocket

	IN NETWORK	OUT OF NETWORK
Deductible	$0	$0
MOOP	$5,500	$10,000 (Combined)

Part A

	IN NETWORK	OUT OF NETWORK
Inpatient Acute	$300 days 1-5;$0 days 6-60	40% Coinsurance
Inpatient Psych	$350 days 1-5;$0 days 6-60	40% Coinsurance
SNF	$0 days 1-20;$184 days 21-100	$0 days 1-20;$184 days 21-100
Home Health	$0	40% Coinsurance

Part B

	IN NETWORK	OUT OF NETWORK
Cardiac & Pulmonary Rehab	$20 Cardiac/Pulm/SET for PAD, $40 Intensive Cardiac Rehab	40% Coinsurance
PT/OT/ST	$10.00	40% Coinsurance
ER	$125.00	$125.00
Urgent Care	$10.00	$10.00
PCP	$0.00	40% Coinsurance
Chiro	$10.00	40% Coinsurance
Specialist	$20.00	40% Coinsurance
Mental Health	$10.00	40% Coinsurance
Podiatry	$10.00	40% Coinsurance
Other Health Care Professional	$0 to $40 ($0 copay at office $40 copay at facility)	40% Coinsurance
Psychiatry	$10.00	40% Coinsurance
Outpatient Lab	$0.00	40% Coinsurance
X-Rays	$0 to $100	40% Coinsurance
Diagnostic Radiology	20% coinsurance for diagnostic imaging (e.g., sonagrams, ultrasounds) – and for advanced imaging (e.g., CT, MRI, PET)	40% Coinsurance
Therapeutic Radiology	20%	40% Coinsurance
Outpatient Hospital Services	$250.00	40% Coinsurance
Outpatient Hospital Observation	$300.00	40% Coinsurance
ASC	$150.00	20% Coinsurance
Outpatient Substance Abuse	$25 Ind / $15 Group	40% Coinsurance
Ambulance – Ground	$300.00	$300.00
Ambulance – Air	$450.00	$450.00
DME	20%	40% Coinsurance
Prosthetics	20%	40% Coinsurance
Medical Supplies	20%	40% Coinsurance
Diabetic Supplies	20%	40% Coinsurance
Therapeutic Shoes or Inserts	20%	40% Coinsurance
Renal Dialysis	20%	40% Coinsurance
Chemotherapy Drugs	20%	40% Coinsurance
Part B Drugs	20%	40% Coinsurance

Part D

	IN NETWORK	OUT OF NETWORK
Deductible	$0	NA
ICL	$2,000	NA
Tier 1 Retail 30/Retail 90/Mail	$0/$0/$0	NA
Tier 2 Retail 30/Retail 90/Mail	$10/$30/$0	NA
Tier 3 Retail 30/Retail 90/Mail	$44/$132/$88	NA
Tier 4 Retail 30/Retail 90/Mail	$95/$285/$285	NA
Tier 5 Retail 30/Retail 90/Mail	33%/33%/33%	NA
Tier 2 Insulin	$10/$30/$0	NA
Tier 3 Insulin	$35/$70/$70	NA
Tier 4 Insulin	$35/$70/$70	NA

Supplemental Benefits

	IN NETWORK	OUT OF NETWORK
Worldwide Emergency	Up to $50,000 Maximum	Up to $50,000 Maximum
Non-Emergency Transportation	50 one-way trips	NA
OTC	$200 per quarter	NA
Meals	2 meals a day for 14 days provided immediately following each surgery or inpatient hospitalization. Up to 2 times per year	NA
Fitness	Silver & Fit	NA
Nursing Hotline	Covered	50% Coinsurance

SSBCI
IN NETWORK
Flex Card $205 / Month to apply towards list below (amount does NOT roll over):
-Gas Card
-Home Safety/Access Modifications
-Social and Active Club Membership
-Internet / Cell Data
Members also get:
$80 /month Grocery Card

OUT OF NETWORK
NA

Other (SSBCI Not required)
IN NETWORK Personal Emergency Response System $500 Flex Card (Dental, Vision and Hearing)
OUT OF NETWORK NA

Dental
IN NETWORK
Dental – Preventative Annual Max Benefit Amount: $2200 combined with Comprehensive Exams: 1 every 6 months Prophylaxis: 1 every 6 months Flouride: 1 every year X-Rays: 1 every 2 years
Dental – Comprehensive Annual Max Benefit Amount: $2200 combined with Preventative Non-Routine Services: Unlimited Diagnostic Services: Unlimited Restorative Services: Unlimited Endodontics: Unlimited Periodontics: Unlimited Extractions: Unlimited Prosthodontics, Other Oral/Maxillofacial Surgery: Unlimited
OUT OF NETWORK
Dental – Preventative 50% Coinsurance
Dental – Comprehensive 50% Coinsurance

Vision
IN NETWORK
Vision – Exams: Medicare Covered – $40, 1 Routine Exam / year – $0
Vision – Hardware: Annual Max Benefit Amount: $400 Contact Lenses Eyeglasses (lenses and frames)
OUT OF NETWORK
Vision – Exams: 50% Coinsurance
Vision – Hardware: 50% Coinsurance

Hearing
IN NETWORK
Hearing – Exams:	Medicare Covered – $40, 1 Routine Exam / year – $0
Hearing – Aids:	$699 or $999 copay per hearing aid, depending on device
OUT OF NETWORK
Hearing – Exams:	50% Coinsurance
Hearing – Aids:	50% Coinsurance, hearing aid up to $2,000

HMO – H1748016

Sonder Vitality Matters

A Plan For active seniors

Additional Plan Benefits

Unless indicated, benefits are per service or per year.
*Only for members who have qualifying chronic medical conditions.
Please see Summary of Benefits for full list of conditions.

Deductible & Max Out-Of-Pocket

Deductible	$0
MOOP	$3,950

Part A

Inpatient Acute	$350 days 1-5;$0 days 6-90
Inpatient Psych	$350 days 1-5;$0 days 6-90
SNF	$0 days 1-20;$184 days 21-100
Home Health	$10

Part B

Cardiac & Pulmonary Rehab	$25 Cardiac/Pulm, $20 SET for PAD, $40 Intensive Cardiac Rehab
PT/OT/ST	$25.00
ER	$125.00
Urgent Care	$30.00
PCP	$0.00
Chiro	$15.00
Specialist	$0.00
Mental Health	$40.00
Podiatry	$40.00
Other Health Care Professional	$40.00
Psychiatry	$40.00
Outpatient Lab	$0.00
X-Rays	$0 to $100
Diagnostic Radiology	$0 For office based diagnostic imaging, $150 for facility based diagnostic imaging (e.g., sonagrams, ultrasounds) – $300 for advanced imaging (e.g., CT, MRI, PET)
Therapeutic Radiology	20%
Outpatient Hospital Services	$0 – $280 ($0 for Orthopedic Procedures)
Outpatient Hospital Observation	$350.00
ASC	$0 – $180 ($0 for Orthopedic Procedures)
Outpatient Substance Abuse	$25 Ind / $15 Group
Ambulance – Ground	$225.00
Ambulance – Air	$750.00
DME	20%
Prosthetics	20%
Medical Supplies	20%
Diabetic Supplies	20%
Therapeutic Shoes or Inserts	20%
Renal Dialysis	20%
Chemotherapy Drugs	20%
Part B Drugs	20%

Part D

Deductible	$0
ICL	$2,000
Tier 1 Retail 30/Retail 90/Mail	$0/$0/$0
Tier 2 Retail 30/Retail 90/Mail	$10/$30/$0
Tier 3 Retail 30/Retail 90/Mail	$44/$132/$88
Tier 4 Retail 30/Retail 90/Mail	$95/$285/$285
Tier 5 Retail 30/Retail 90/Mail	33%/33%/33%
Tier 2 Insulin	$10/$30/$0
Tier 3 Insulin	$35/$70/$70
Tier 4 Insulin	$35/$70/$70

Supplemental Benefits

Worldwide Emergency	Up to $50,000 Maximum
Non-Emergency Transportation	50 one-way trips
OTC	$125 per quarter
Meals	2 meals a day for 14 days provided immediately following each surgery or inpatient hospitalization. Up to 2 times per year
Fitness	Silver & Fit
Nursing Hotline	Covered

SSBCI
Flex Card $250 / Month to apply towards list below (amount does NOT roll over):
-Gas Card
-Home Safety/Access Modifications
-Social and Active Club Membership (includes out of network gym and wellness centers)
-Internet / Cell Data
-Pet Supplies
-Salon Care – Hair, Manicure, etc…

Members also get:
$90 Grocery Card
$40/month towards weight loss program of your choice

Other (SSBCI Not required)
Flex: $100/month – Stamina/Yoga/Exercise program
Routine foot care $0 – 6 visit per year
Routine Chiro – $0 Copay 12 visits per year
Dental, Vision, Hearing Flex Card: $500
Platelet Rich Plasma – 6 visits / year
Additional excluded drug coverage (generic Viagra, generic Cialis, generic Levitra, generic Bromfed DM and generic Propecia)
Nutritional Dietary Needs up to 6 sessions per year

Dental
Dental – Preventative
Annual Max Benefit Amount: $2000 combined with Comprehensive
Exams: 1 every 6 months
Prophylaxis: 1 every 6 months
Flouride: 1 every 6 months
X-Rays: 1 every 2 years
Dental – Comprehensive
Annual Max Benefit Amount: $2000 combined with Preventative
Non-Routine Services: Unlimited
Diagnostic Services: Unlimited
Restorative Services: Unlimited
Endodontics: Unlimited
Periodontics: Unlimited
Extractions: Unlimited
Prosthodontics, Other Oral/Maxillofacial Surgery: Unlimited

Vision
Vision – Exams:
Medicare Covered – $30, 1 Routine Exam / year – $0
Vision – Hardware:
Annual Max Benefit Amount: $200
Contact Lenses
Eyeglasses (lenses and frames)

Hearing
Hearing – Exams	Medicare Covered – $30, 1 Routine Exam / year – $0
Hearing – Aids	$699 or $999 copay per hearing aid, depeding on device

Do You Have Plan & Benefit Questions?

We are here to help!

If you are a Sonder Health Plans member and have questions about your benefits, please contact the Toll-Free Sonder Member Services Center
1 (888) 428-4440
TTY/TDD 711

Monday through Friday, 8:00 a.m. to 6:00 p.m.

If you are a prospective Sonder Health Plans member and are interested in learning more about us, please call a licensed agent at

(888) 217-7110 7 days a week 8:00 a.m. to 6:00 p.m.

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HMO – H1748015

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Expanded Access To Out-of-Network Providers

HMO – H1748016

Sonder Vitality Matters

A Plan For active seniors

Additional Plan Benefits

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