Program Guide and Member Guidelines

Summary Benefit Plan Document

SakeOf is a peer to peer community that coordinates funding of eligible medical bills after verification and fair price review. It is not insurance.

• Effective date November 1, 2025
• Disclosure participation does not satisfy federal or state minimum essential coverage requirements

Plans and what they include

• Full Service everyday care and major events, advocacy, bill verification and negotiation, prescription savings, virtual primary care, virtual urgent care, and virtual behavioral health. Eligible for community funding after the member commitment
• Major Medical Only focus on large unexpected events with a lower monthly ask cap. Everyday virtual care and prescription savings are included. Eligible for community funding after the member commitment
• No networks visit any licensed provider. We help you find fair price options when you want support

Membership fees and monthly caps

• Base membership fee 50 dollars per member per month. This funds advocacy, technology, bill review, and support
• Community ask cap, Full Service
  • Ages 0 to 25, up to 140 dollars per month
  • Ages 26 to 55, up to 220 dollars per month
  • Ages 56 to 65, up to 320 dollars per month
  • Ages 65 and older, up to 420 dollars per month
• Community ask cap, Major Medical Only
  • Ages 0 to 25, up to 110 dollars per month
  • Ages 26 to 55, up to 180 dollars per month
  • Ages 56 to 65, up to 240 dollars per month
  • Ages 65 and older, up to 340 dollars per month
• Households total monthly cap is the sum of each member by age band and selected plan
• One time application fee 100 dollars collected at enrollment
• One time card issuance fee 7.50 dollars per member for the SakeOf wallet and Visa card

Your cap is the most the community may ask from you in a single month. Actual requests may be lower based on verified need and savings from negotiation

Member commitment per event

• Full Service 500 dollars for a standard health event and 5,000 dollars for maternity
• Major Medical Only 25,000 dollars for a standard event and 15,000 dollars for maternity
• After you meet the member commitment the community funds the eligible remainder up to plan limits

What is eligible

• Medically necessary services for illness or injury
• Emergency and urgent care
• Diagnostics, labs, and imaging
• Hospitalization and surgery
• Ambulance when medically necessary
• Therapies when ordered by a licensed provider
• Maternity when eligible by plan and waiting period
• Items pass eligibility review and fair price verification

How it works

1. 1Choose any licensed provider. For services estimated at 500 dollars or more, use your SakeOf Visa card so we can check and secure fair pricing
2. 2Present your SakeOf Visa card or request a cash estimate and itemized bill. If you pay out of pocket, submit itemized bills and receipts in the portal or app
3. 3SakeOf reviews medical necessity and fair pricing, including repricing bills over 500 dollars before funding. We negotiate as needed and confirm what is eligible
4. 4After you meet the member commitment and are active and current on your community asks, the eligible remainder is funded by the community up to plan limits. Funds are sent to your SakeOf wallet or to the provider where accepted

Bills over 500 dollars should be routed through your SakeOf card whenever possible so we can secure fair pricing before funding. For large planned care contact us in advance so we can secure fair pricing and improve funding outcomes

Policies that support fairness and participation

Price fairness policy

• SakeOf targets fair market cash pricing in your region
• For planned care we may request a second option when a quoted price is well above fair market levels
• Bills that reflect unreasonable pricing may have limited eligibility until negotiation completes

Participation policy

• Requests to fund others are voluntary
• Consistent participation helps stabilize monthly asks for the community
• Members who regularly help when able tend to see faster fulfillment when they need help
• To be eligible for community funding you must keep your membership active. Active means your base fee is paid, your wallet is funded with the current month’s community ask, and any past due asks are made current
• If you are not active or not current on your asks, new medical events are not eligible for submission or funding until your participation is brought up to date

Pre existing conditions and waiting periods

• Months 0 to 12 not shareable
• Months 13 to 24 up to 25,000 dollars per year
• Months 25 to 36 up to 50,000 dollars per year
• After 36 months fully shareable

Wellness and virtual care

• 24/7 nationwide urgent care telemedicine visits at no cost to you
• Acute prescriptions with 70 commonly used drugs free at more than 60,000 pharmacies, with no limits on dose, duration, or frequency when clinically appropriate
• On demand virtual counseling with masters level counselors, with unlimited sessions
• These virtual and wellness services are included for both Full Service and Major Medical Only members. Wellness and screening services may be guided to fair price options, and some items may not be eligible for community funding

Pharmacy

• Use prescription savings tools provided by SakeOf when available
• Choose generic options when clinically appropriate
• Maintenance drugs are generally limited to a twelve month supply per membership life

Maternity and family

• Maternity eligibility per plan with a waiting period
• Newborn must be added within thirty days of birth to enable funding from the date of birth
• Family totals use each member age band and plan to calculate the monthly cap

Member responsibilities

• Keep membership active by paying the base fee each month and staying current on monthly asks and any past due amounts
• Maintain a valid payment method and load your wallet so that your monthly ask can be collected
• Pay your member commitment when it applies
• Submit complete and itemized bills within six months of the date of service
• Notify SakeOf for planned care so we can assist with navigation and negotiation

Admin and late fees

• Late payment 15 dollars
• Reactivation 25 dollars
• Returned payment 25 dollars

Exclusions

• Cosmetic or elective services
• Services that are not medically necessary
• Items outside published limits or categories
• Illegal or fraudulent activity
• Experimental items that lack evidence of benefit

Eligibility and enrollment

• Open to adults eighteen to sixty five who meet participation criteria. Minors may enroll as members with an adult guardian, including grandparents over sixty five, who manages the account and wallet on their behalf
• Rules may vary by state
• SakeOf may request medical records to validate eligibility and to negotiate fair pricing

Account wallet and payments

• Each member receives a SakeOf wallet and Visa card. Your wallet has a participation balance that you load for your monthly asks and fees, and a funding balance where approved community funds are deposited
• Funds for approved items are sent to the funding balance in your SakeOf wallet or paid directly to providers where accepted. Funding balances may be limited to eligible medical and related expenses
• Use your SakeOf Visa debit for approved transactions and for services where we are securing fair pricing, especially when bills are over 500 dollars
• If a negotiated price is reduced after payment members agree in good faith to return excess funds to the community

Changes cancellation and reinstatement

• You may change plans. Changes apply to new events. Events tie to the plan in effect when symptoms began
• You may cancel any time. Cancellation is effective at the end of the current billing cycle
• Reinstatement may require a waiting period and payment of any fees

How to get the most from your membership

• Start events in the app before planned care when possible
• Ask for itemized bills and cash estimates
• Use your SakeOf card and navigation to compare options and secure fair prices, especially when care is expected to cost more than 500 dollars
• Upload documents promptly and respond to requests from the team