Elite Signature HMO (HMO)
Available to residents of San Bernardino County, CA for 2026. Contract H6368, plan 001, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in San Bernardino County
- Plan website
- Browse the Elite Signature HMO (HMO) formulary
New for 2026. This plan has no 2025 predecessor in the CMS crosswalk.
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $699.00? |
| Drug deductible | $0.00 |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO? |
| Contract / plan | H6368-001-0 |
| Offered by | Elite Health Plan, Inc. |
| Parent organization | Elite Health Systems, Inc. |
| Formulary drugs | 3,250 |
| Formulary exception tier | 5? |
| Pharmacy search | www.elitheatlhplaninc.com |
| Member services | (800)958-1129TTY 711 |
CMS star ratings
- Overall
- —
- Health plan (Part C)
- —
- Drug plan (Part D)
- —
Published per contract — every plan under contract H6368 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $0 copay(authorization and referral required) |
| Other health care professional | $0 copay(referral required) |
| Additional telehealth services | $0 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay(referral required) |
| Diabetes self-management training | $0 copay(referral required) |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $0 copay(authorization and referral required) |
| Lab services | $0 copay(authorization and referral required) |
| Diagnostic radiology (e.g. MRI, CT) | $0 copay(authorization and referral required) |
| Therapeutic radiology | $0 copay(authorization and referral required) |
| Outpatient x-rays | $0 copay(authorization and referral required) |
| Emergency and urgent care | |
| Emergency room | $95 copay |
| Urgent care | $0 copay |
| Worldwide emergency coverage | $100 copay · $10,000 plan limit |
| Worldwide urgent care | $50 copay · $10,000 plan limit |
| Worldwide emergency transportation | $100 copay |
| Hospital care | |
| Inpatient hospital stay | $75 per day for days 1–5; $0 per day for days 6–90(authorization and referral required) |
| Outpatient hospital services | $0 copay(authorization and referral required) |
| Outpatient observation | $0 copay(authorization and referral required) |
| Ambulatory surgical center | $0 copay(authorization and referral required) |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $50 per day for days 21–100(authorization and referral required) |
| Home health care | $0 copay(referral required) |
| Kidney dialysis | 20% coinsurance(authorization and referral required) |
| Rehabilitation | |
| Occupational therapy | $0 copay(authorization and referral required) |
| Physical therapy and speech-language therapy | $0 copay(authorization and referral required) |
| Cardiac rehabilitation | $0 copay(authorization and referral required) |
| Pulmonary rehabilitation | $0 copay(authorization and referral required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $75 per day for days 1–5; $0 per day for days 6–90(authorization and referral required) |
| Outpatient mental health, individual session | $25 copay(authorization and referral required) |
| Outpatient mental health, group session | $0 copay(authorization and referral required) |
| Psychiatrist, individual session | $25 copay(authorization and referral required) |
| Psychiatrist, group session | $0 copay(authorization and referral required) |
| Partial hospitalization | $0 copay(authorization and referral required) |
| Intensive outpatient program | $0 copay(authorization and referral required) |
| Outpatient substance use, individual session | $25 copay(authorization and referral required) |
| Outpatient substance use, group session | $0 copay(authorization and referral required) |
| Opioid treatment program | 20% coinsurance(authorization and referral required) |
| Ambulance and transportation | |
| Ground ambulance | $100 copay(authorization required) |
| Air ambulance | 20% coinsurance(authorization required) |
| Transportation to plan-approved locations | $0 copay |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 0%–20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | 0%–20% coinsurance(authorization required) |
| Diabetic therapeutic shoes or inserts | 0%–20% coinsurance(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $0 copay |
| Routine chiropractic care | $10 copay(limits apply) |
| Acupuncture | $10 copay(limits apply) |
| Foot exams and treatment (Medicare-covered) | $0 copay |
| Routine foot care | $10 copay(limits apply) |
| Dental? | |
| Medicare-covered dental services | $0 copay |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | $0 copay(limits apply) |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | $0 copay(limits apply) |
| Other preventive dental services | $0 copay(limits apply) |
| Endodontics (root canals) | Not covered |
| Dentures and other removable prosthodontics | Not covered |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | Not covered |
| Orthodontics | Not covered |
| Vision? | |
| Eye exam (Medicare-covered) | $0 copay |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| Eyewear plan limit | $250 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | $0 copay(limits apply) |
| Hearing? | |
| Hearing exam (Medicare-covered) | $0 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay |
| Hearing aids (all types) | $399–$949 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | $35 copay(authorization required) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required) |
| Other Part B drugs | 0%–20% coinsurance(authorization required) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $65 allowance every three months |
| Meals after a hospital stay or for a chronic condition | $0 copay(authorization and referral required) |
| Fitness benefit | $0 copay(authorization and referral required) |
| Health education | $0 copay(authorization and referral required) |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | Not covered |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | $0 copay(authorization and referral required) |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | $0 copay(authorization and referral required) |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $0.00 |
| Tier 3 | $35.00 |
| Tier 4 | $98.00 |
| Tier 5 | 33% |
| Tier 6 | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $35.00 | $35.00 | n/a | $105.00 | $105.00 | $105.00 |
| Tier 4: Non-Preferred Drug | $98.00 | $98.00 | n/a | n/a | n/a | n/a |
| Tier 5: Specialty Tier | 33% | 33% | n/a | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 2 other CA counties
Benefits in plain text
Elite Signature HMO (HMO) (H6368-001-0) is a 2026 HMO Medicare Advantage plan offered by Elite Health Plan, Inc., available to residents of San Bernardino County, CA.
The monthly premium is $0.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $699.00.
The drug deductible is $0.00.
The plan's formulary lists 3,250 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $0.00; tier 3: $35.00; tier 4: $98.00; tier 5: 33%; tier 6: $0.00.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.