Conventional Plan for 2014

Samaritan Advantage Conventional Plan HMO for 2014

The Samaritan Advantage Conventional Plan HMO offers you some of the most generous Medicare medical benefits available in Corvallis, Albany, Lebanon, Sweet Home, Newport, Lincoln City and other cities in Linn, Benton and Lincoln Counties, Oregon.

Below you will find coverage information for Samaritan Advantage Conventional Plan HMO. These materials are important documents that describe your health insurance benefits in detail.

2014 Summary of Benefits
Conventional Plan (PDF) CMS Approved

2014 Evidence of Coverage 
Conventional Plan (PDF) CMS Approved

CONVENTIONAL PLAN HMO
$72 month
2014 BENEFIT HIGHLIGHTS
Deductible         $0 annual deductible
Medical out-of-pocket maximum $3,400 (The most you will pay per year for medical co-pays and coinsurance)
Hospitalization Out-of-pocket limit: $1,750/year
$175/day for days 1-5
$0/day for days 6-90
Doctor office visits Primary care visit: $10 co-pay
Specialist visit: $20 co-pay
Emergency care

Worldwide coverage: $50 co-pay
$0 co-pay if you are admitted to the hospital within 12 hours
$100 co-pay for ambulance

Urgent Care Anywhere in the U.S.: $25 co-pay
Routine physical exams $0 co-pay
Skilled nursing facility care Days 1-120 in a facility: $40 co-pay
Chiropractic services
Acupuncture
$20 co-pay for manual manipulation of the spine to correct subluxation
$25 co-pay for up to 5 routine chiropractic visits per year
$20 co-pay per acupuncture visit; up to 15 visits per year
Vision services
(Eye wear does not apply
to annual medical out-of-pocket maximum)
Treatment of eye conditions & diseases: $20 co-pay
Routine eye exam: $20 co-pay for each; limited to 1 exam every 2 years
Eyewear: up to $125 for every 2 years
Preventive and diagnostic services $0 co-pay for:
Medicare-covered bone mass measurements, colorectal screening, flu and pneumonia vaccines
Mammograms
Pap smears
Pelvic exams
Prostate cancer screening
Diagnostic tests
Lab services
Outpatient Prescription Drugs NO.
Only available with the Premier and Premier Plan Plus HMO Plans.
Dental Benefit
(Does not apply to annual medical out-of-pocket maximum)
NO.
Only available with the Premier Plan Plus HMO.
Hearing Aids Benefit
(Does not apply to annual medical out-of-pocket maximum)
NO.
Only available with the Premier Plan Plus HMO.
Out-of-pocket maximum for durable medical equipment NO.
Only available with the Premier Plan Plus HMO.

What are my rights as a member?
As a member of Samaritan Advantage Health Plan HMO you have the right to make a complaint if you have concerns or problems related to your coverage or care or ask us to cover a specific medical service. Read about your rights as our member for additional information.

Last modified: Aug. 4, 2014
H3811_MA4001_2013A CMS Approved 11/06/2013