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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 Copay on Your PCP Visits
when you become a Sonder member
Vision, Hearing and Dental Benefits in Every Plan
$0 Copay on Your PCP Visits
when you become a Sonder Diabetes Wellness member
Vision, Hearing and Dental Benefits in Every 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 |
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 |
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 |
| 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 |
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 |
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 |
| 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 |
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 |
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.
