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SummaCare Medicare Topaz (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for SummaCare Medicare Topaz (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on SummaCare Medicare Topaz (HMO) in 2025, please refer to our full plan details page.
SummaCare Medicare Topaz (HMO) is a HMO plan offered by Summa Health available for enrollment in 2025 to people living in Northeast Ohio + ER, HU, OT, SA, & SE Counties. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that SummaCare Medicare Topaz (HMO) 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 Topaz (HMO).
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 Topaz (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $2.20. You must continue to pay paying your reduced 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 $200.00 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 $4000.00 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 Topaz (HMO) plan has a $200 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy type. For example, the copay for a standard generic drug is $47, while the copay for a preferred brand drug is $100. Non-preferred drugs have a 30% coinsurance, and there is no copay for specialty tier drugs.
Additional Benefits
The SummaCare Medicare Topaz (HMO) plan offers coverage for a wide range of healthcare services. This includes inpatient and outpatient hospital care, with varying copays depending on the service. Emergency services, primary care, preventive services, hearing, vision, and dental are also included, with specific copays, coinsurance, and annual limits applying to certain services. Additional benefits of this plan include ambulance services, partial hospitalization, home health services, and medical equipment. The plan also offers coverage for home infusion, dialysis, skilled nursing facilities, and other services like acupuncture and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with prior authorization. For Inpatient Hospital-Acute, you pay a $375 copay for days 1-6, and no copay for days 7-90. For Inpatient Hospital Psychiatric, you pay a $375 copay for days 1-5, and no copay for days 6-90. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered by SummaCare Medicare Topaz (HMO), 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 $310 copay, while individual and group sessions for outpatient substance abuse have a copay between $35 and $35. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the SummaCare Medicare Topaz (HMO) plan. The copay for this benefit is $45.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including both ground and air ambulance services with a $320 copay, and transportation services to plan-approved health-related locations for 6 one-way trips per year. Transportation services to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage have a copay of $120, $30, $120, and $30, respectively, with no coinsurance. Worldwide Emergency Transportation has a $320 copay with no coinsurance.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Chiropractic Services have a $20 copay, Occupational Therapy Services have a $35 copay, Physician Specialist Services have a $35 copay, Other Health Care Professional services have a copay between $20 and $35, and Physical Therapy and Speech-Language Pathology Services have a $35 copay. Mental Health and Psychiatric Services have a $35 copay for individual and group sessions, and Additional Telehealth Benefits have a copay between $0 and $20. 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, additional preventive services with a copay, health education, kidney disease education, and other preventive services. Annual physical exams, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, readmission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, telemonitoring services, home and bathroom safety devices and modifications, and counseling services are not covered. Therapeutic massage has a $20 copay for up to 6 sessions per year.
Hearing Services See details
Hearing exams are covered with no copay, and routine hearing exams are limited to 1 visit per year. Prescription hearing aids are covered with a copay between $395 and $695 for all types, but inner ear, outer ear, and over the ear prescription hearing aids are not covered. Fitting/evaluation for hearing aids are covered with no limit. OTC hearing aids are not covered.
Vision Services See details
Vision services include coverage for routine eye exams, eyewear, and upgrades. Eyewear has a combined maximum benefit of $200.00 every year, and includes coverage for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames.
Dental Services See details
The SummaCare Medicare Topaz (HMO) plan covers a variety of dental services, including oral exams (2 per year), dental x-rays (limited), prophylaxis (cleaning) (2 per year), and fluoride treatment (1 per year). Restorative services and oral and maxillofacial surgery are covered with 0-20% coinsurance, while prosthodontics (removable and fixed) have 20% coinsurance; however, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. 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 under the SummaCare Medicare Topaz (HMO) plan with a 20% coinsurance. There is no copay for this benefit.
Medical Equipment See details
The SummaCare Medicare Topaz (HMO) plan covers Durable Medical Equipment (DME) with 30% coinsurance and no copay, but does not cover DME for use outside the home. Prosthetics/Medical Supplies have no copay, and a coinsurance applies to Medicare-covered prosthetic devices and medical supplies. Diabetic Therapeutic Shoes/Inserts are covered with 20% coinsurance, but Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the SummaCare Medicare Topaz (HMO) plan. Diagnostic Procedures/Tests have a copay between $0 and $125, while Lab Services have no copay. Diagnostic Radiological Services have a copay of $175, Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a $75 copay.
Home Health Services See details
Home Health Services are covered by the SummaCare Medicare Topaz (HMO) 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 technically covered, but this 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 Topaz (HMO) plan, with a $0 copay for days 1-20, and a $203 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
The SummaCare Medicare Topaz (HMO) plan covers acupuncture with a $20 copay per visit for up to 6 treatments per year, and over-the-counter items with a $90 maximum benefit every three months, including nicotine replacement therapy and Naloxone. This plan's meal benefit is covered for chronic illnesses, and other services, including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, are not covered.
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