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SummaCare Medicare Sapphire (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for SummaCare Medicare Sapphire (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on SummaCare Medicare Sapphire (HMO-POS) in 2026, please refer to our full plan details page.
SummaCare Medicare Sapphire (HMO-POS) is a HMO-POS plan offered by Summa Health available for enrollment in 2025 to people living in Northern Ohio. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that SummaCare Medicare Sapphire (HMO-POS) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about SummaCare Medicare Sapphire (HMO-POS).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For SummaCare Medicare Sapphire (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $83.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $50.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3650.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The SummaCare Medicare Sapphire (HMO-POS) prescription drug plan features an affordable annual drug deductible of $50. Members benefit from no copay on Tier 1 (Preferred Generic), Tier 2 (Generic), and Tier 6 (Select Care Drugs) when filled at a preferred pharmacy or through standard mail order. For standard pharmacies, one-month copays for these lower-tier drugs range from $6 to $10. Tier 3 (Preferred Brand) drugs require a $41 copay at preferred pharmacies or a $47 copay at standard pharmacies for a one-month supply. Higher-tier medications are subject to coinsurance, with Tier 4 (Non-Preferred) drugs requiring 40% to 50% coinsurance and Tier 5 (Specialty) drugs requiring 32% coinsurance.
Additional Benefits
The SummaCare Medicare Sapphire (HMO-POS) plan offers comprehensive medical coverage with no copay for primary care visits and a $35 copay for specialist appointments. For hospital care, inpatient stays require a $240 daily copay for the first several days with no coinsurance, while outpatient hospital services carry a $210 copay. Emergency room visits are covered with a $120 copay, which is waived if admitted, and urgent care services require a $25 copay. In addition to medical care, members benefit from no copay on routine dental, vision, and hearing exams, plus a $305 annual allowance for eyewear and a $75 quarterly over-the-counter allowance. Skilled nursing facility care features no copay for the first 20 days, and home health services are provided with no copay and no coinsurance. The plan also includes up to 10 free one-way transportation trips to approved health locations per year.
Inpatient Hospital See details
SummaCare Medicare Sapphire (HMO-POS) covers inpatient hospital services with no coinsurance, requiring a $240 daily copay for days 1 through 6 of acute stays (no copay for days 7 and beyond) and a $240 daily copay for days 1 through 5 of psychiatric stays (no copay for days 6 through 90). Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
SummaCare Medicare Sapphire (HMO-POS) covers outpatient services with no coinsurance, including outpatient hospital and observation services for a $210 copay and ambulatory surgical center services for a $170 copay. Outpatient substance abuse sessions require a $35 copay with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
SummaCare Medicare Sapphire (HMO-POS) covers partial hospitalization services with a $40.00 copay and no coinsurance.
Ambulance and Transportation Services See details
SummaCare Medicare Sapphire (HMO-POS) covers ambulance services with a $200 copay and no coinsurance for both ground and air transport. Transportation services are partially covered, offering up to 10 one-way trips per year to plan-approved health locations with no copay and no coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
SummaCare Medicare Sapphire (HMO-POS) covers emergency services with a $120 copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $25 copay, both with no coinsurance. Worldwide emergency and urgent services are also covered up to a $25,000 maximum lifetime benefit, featuring no coinsurance and copays of $120 for emergency care, $25 for urgent care, and $200 for emergency transportation.
Primary Care See details
SummaCare Medicare Sapphire (HMO-POS) provides primary care and opioid treatment services with no copay and no coinsurance, while specialists, mental health, psychiatric, and physical therapy services require a $35 copay and no coinsurance. Chiropractic care is partially covered with a $20 copay and no coinsurance, though routine and other chiropractic services are not covered, telehealth ranges from a $0 to $20 copay with no coinsurance, and podiatry is not covered.
Preventive Services See details
SummaCare Medicare Sapphire (HMO-POS) provides coverage for preventive services, including Medicare-covered zero-dollar preventive services, kidney disease education, and select screenings with no copay and no coinsurance. Additional preventive services are partially covered, offering benefits like health education and fitness programs with no copay and no coinsurance, while excluding services such as annual physical exams, in-home safety assessments, and personal emergency response systems.
Hearing Services See details
SummaCare Medicare Sapphire (HMO-POS) covers hearing services with no copay and no coinsurance for one routine hearing exam per year and unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $395 to $695 for up to two aids per year, though inner ear, outer ear, over the ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Vision services are covered by SummaCare Medicare Sapphire (HMO-POS) with no copay, no coinsurance, and no deductible, although other eye exam services are not covered. This partially covered benefit includes one routine eye exam per year and up to $305 annually for eyewear, including contact lenses, eyeglasses, and upgrades.
Dental Services See details
Dental services are partially covered by SummaCare Medicare Sapphire (HMO-POS), offering no copay and no coinsurance for preventive care up to a $2,000 annual limit. Covered comprehensive services require no copay and 0% to 70% coinsurance, while orthodontics, implants, maxillofacial prosthetics, other diagnostic, and other preventive dental services are not covered.
Home Infusion bundled Services See details
SummaCare Medicare Sapphire (HMO-POS) covers home infusion bundled services with no copay and no coinsurance, subject to prior authorization. Under this benefit, Medicare Part B insulin drugs are covered with a $35 copay and no coinsurance, while other covered Part B drugs, including chemotherapy and radiation, have no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the SummaCare Medicare Sapphire (HMO-POS) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
SummaCare Medicare Sapphire (HMO-POS) offers medical equipment coverage with no copay and a 20% coinsurance for durable medical equipment, prosthetic devices, medical supplies, and diabetic shoes or inserts. This benefit is partially covered, as diabetic supplies are not covered by the plan, and prior authorization is required for some services.
Diagnostic and Radiological Services See details
SummaCare Medicare Sapphire (HMO-POS) covers diagnostic and radiological services with prior authorization required. Diagnostic services feature no coinsurance, with no copay for lab services and a $0 to $99 copay for tests, while radiological services require a minimum $150 copay for diagnostic radiology, a minimum 20% coinsurance for therapeutic radiology, and no copay for outpatient X-rays.
Home Health Services See details
Home Health Services are covered by SummaCare Medicare Sapphire (HMO-POS) with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are provided by SummaCare Medicare Sapphire (HMO-POS) with no copay and no coinsurance; although some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
SummaCare Medicare Sapphire (HMO-POS) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 to 20 and a $195 copay for days 21 to 100. Prior authorization is required and a prior three-day hospital stay is not needed, though additional days beyond the standard Medicare-covered period are not covered.
Other Services See details
SummaCare Medicare Sapphire (HMO-POS) partially covers other services, providing a meal benefit for chronic illness and a $75 quarterly over-the-counter (OTC) allowance with no copay and no coinsurance. Acupuncture is not covered under this benefit.
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