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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 2025, 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 2025.
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 $80.00. 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) plan has a $50 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, you will pay no copay for preferred generic drugs at a standard pharmacy, a $46 copay for standard generic drugs, and a $100 copay for preferred brand drugs. Non-preferred drugs have a 32% coinsurance, and specialty tier drugs have no copay. After your total yearly drug costs reach $2000, you will enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The SummaCare Medicare Sapphire (HMO-POS) plan offers a range of benefits, including inpatient hospital stays with copays, outpatient services with copays, and coverage for ambulance and emergency services. The plan also covers primary care, preventive services, hearing, vision, and dental services, each with specific copays, coinsurance, and annual maximums. Additional benefits include home health services with no copay, and skilled nursing facility stays with a copay after day 20. This plan provides some additional benefits, such as coverage for home infusion services, dialysis, medical equipment, and diagnostic and radiological services. It also offers a quarterly allowance for over-the-counter items and a meal benefit for chronic illnesses. However, it's important to note that certain services like cardiac rehabilitation, additional home health care, and some dental and vision services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered by the SummaCare Medicare Sapphire (HMO-POS) plan. For Inpatient Hospital-Acute, there is a $240 copay for days 1-6, and no copay for days 7-90. For Inpatient Hospital Psychiatric, there is a $240 copay for days 1-5, and no copay for days 6-90. Additional Days for Inpatient Hospital-Acute are covered with no copay, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered by the SummaCare Medicare Sapphire (HMO-POS) plan, including all outpatient hospital services, observation services, ambulatory surgical center services, and outpatient substance abuse services. Outpatient hospital services, observation services, and ambulatory surgical center services have a copay of $205.00, while individual and group sessions for outpatient substance abuse have a copay between $35.00 and $35.00. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the SummaCare Medicare Sapphire (HMO-POS) plan. This benefit has a $40 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with a $200 copay for both ground and air ambulance services, and no coinsurance. Transportation Services to a plan-approved health-related location are covered for up to 10 one-way trips per year via taxi or bus/subway. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $120 copay, and Urgently Needed Services have a $25 copay. Worldwide Emergency Services have a $120 copay for Worldwide Emergency Coverage, a $25 copay for Worldwide Urgent Coverage, and a $200 copay for Worldwide Emergency Transportation.
Primary Care See details
The SummaCare Medicare Sapphire (HMO-POS) plan covers primary care services, chiropractic services with a $20 copay, occupational therapy services with a $35 copay, physician specialist services with a $35 copay, and mental health specialty services. The plan also covers physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits with a $0-$20 copay, and opioid treatment program services. However, routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with no copay, as well as additional preventive services such as health education, smoking cessation counseling, fitness benefits, enhanced disease management, remote access technologies and kidney disease education services. This plan does not cover annual physical exams, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, support for caregivers of enrollees, telemonitoring services, home and bathroom safety devices and modifications, and counseling services.
Hearing Services See details
Hearing services include hearing exams with no copay, routine hearing exams once per year, and fitting/evaluation for hearing aids. Prescription hearing aids are covered with a copay between $395 and $695 for all types of hearing aids, but not for inner ear, outer ear, or over the ear hearing aids. OTC hearing aids are not covered.
Vision Services See details
The SummaCare Medicare Sapphire (HMO-POS) plan covers vision services, including routine eye exams with one visit per year. Eyewear is covered with a combined maximum benefit of $305.00 per year, while contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
The SummaCare Medicare Sapphire (HMO-POS) plan covers dental services with a maximum benefit of $2,000 per year. Oral exams are covered for up to 2 visits per year, dental x-rays are covered with limits, prophylaxis (cleaning) is covered for up to 2 visits per year, and fluoride treatments are covered for 1 visit per year. Restorative services, endodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with coinsurance between 50% and 70%. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the SummaCare Medicare Sapphire (HMO-POS) plan. You will pay 20% coinsurance for dialysis services.
Medical Equipment See details
Medical equipment is covered under the SummaCare Medicare Sapphire (HMO-POS) plan, with a 20% coinsurance for Durable Medical Equipment, Prosthetic Devices, and Medical Supplies, but Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered. Diabetic Therapeutic Shoes/Inserts are covered with a 20% coinsurance.
Diagnostic and Radiological Services See details
The SummaCare Medicare Sapphire (HMO-POS) plan covers diagnostic and radiological services, including diagnostic procedures and tests with a copay of $0 to $99, and lab services with no copay. Diagnostic radiological services have a copay of at least $150, while therapeutic radiological services have at least 20% coinsurance. Outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered by the SummaCare Medicare Sapphire (HMO-POS) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the SummaCare Medicare Sapphire (HMO-POS) plan. The plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the SummaCare Medicare Sapphire (HMO-POS) plan, but require prior authorization. There is no copay for days 1-20, and a $195 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The SummaCare Medicare Sapphire (HMO-POS) plan offers a $75 allowance every three months for over-the-counter items, including nicotine replacement therapy and Naloxone, and a meal benefit for chronic illnesses. Acupuncture, Dual Eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and many other services are not covered.
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