HMO – H1748005

Sonder Dual Complete

For Dual-Eligible for Medicare/Medicaid Members (D-SNP Plan)

Premium and Out of Pocket Limits
Monthly Plan Premium
$0 Copay
Annual Deductible
$0
Max-Out-Of-Pocket (MOOP)
$3,850
Provider Office Visits
Primary Care Physician (PCP) Visit
$0 Copay
Specialist Visit
$0 Copay
Urgent Care
$0 Copay
Wellness and Preventative Care
Annual Wellness Exam
$0 Copay – 100% Coverage by Plan
Preventative Screenings & Immunization
$0 Copay – 100% Coverage by Plan
Silver and Fit Gym Benefit
$0 Copay – 100% Coverage by Plan
Surgical and Emergency Care
Hospital Inpatient
$0 Copay
Hospital Outpatient
$0 Copay
Ambulatory Surgery Center (ASC)
$0 Copay
$0 Copay
Emergency Room
$0 Copay
Skilled Nursing Facility
$0 Copay
Home Health
$0 Copay
Rehab/DME and Lab/Radiology
Physical/Occupational/Speech Therapy
$0 Copay/$0 Copay/$0 Copay
Durable Medical Equipment
$0 Copay
Diagnostic Radiology (ie. CT or MRI)
$0 Copay
Lab Services
$0 Copay
Outpatient X-Rays
$0 Copay
Cardiovascular & Pulmonology Rehab
$0
Diabetic Supplies
$0 Copay
Rx Drug Coverage – Elixer Rx Options

(1-Month/3-Month/Mail Order)
Tier 1 Drugs – Preferred Generics
$0 Copay/$0 Copay/$0 Copay
Tier 2 – Non-Preferred Generics
$0 Copay/$0 Copay/$0 Copay
Tier 3 – Preferred Brands
$0 Copay/$0 Copay/$0 Copay
Tier 4 – Non-Preferred Brands
$0 Copay/$0 Copay/$0 Copay
Tier 5 – Specialty Drugs
0% Coinsurance/0% Coinsurance/0% Coinsurance
Additional Services
24/7 Nurse Hotline
Yes
Over the Counter
$500 per Quarter
Transportation Allowance (per year)
$0 Copay for up to 50 One-Way Trips
Grocery Card
$75 Monthly Benefit
Comprehensive & Preventative Dental Services
Exams
$0 Copay 1 every 6 months
Prophylaxis
$0 Copay 1 every 6 months
Fluoride
$0 Copay 1 every year
X-Rays
1 every 2 years
Non-Routine Services
$0 Copay
Diagnostic Services
$0 Copay
Restorative Services
$0 Copay
Endodontics
$0 Copay
Periodontics
$0 Copay
Extractions
$0 Copay
Prosthodontics, Other Oral/Maxillofacial Surgery
$0 Copay
Combined Maximum Benefit
$5,000
Vision Services

*$0 Copay and $3,500 allowance if vision option is selected
Routine Eye
$0 Copay
Eyewear (Lenses, Frames, Contacts)
$500 Per Year Allowance
Hearing Services

*$0 Copay and $3,000 allowance if hearing option is selected
Hearing Exams
$0 Copay
Hearing Aids
$0 Copay
Additional Benefits
Meals Covered
14 Days (28 Meals Max)
Podiatry Services (Medicare Covered)
$0 Copay
Chiropractic Services
$0 Copay