2012 Premier Plan Plus
Samaritan Advantage Premier Plan Plus HMO for 2012
PREMIER PLAN PLUS HMO
$121 month |
2012 BENEFIT HIGHLIGHTS* |
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Hospitalization
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Out-of-pocket limit: $1,500/year
$150/day for days 1-5
$0/day for days 6-90
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Doctor office visits
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Primary care visit: $10 co-pay
Specialist visit: $20 co-pay
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Emergency care
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Worldwide coverage: $50 co-pay
$0 co-pay if you are admitted to the hospital within 12 hours
$50 co-pay for ambulance
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Urgent Care
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Anywhere in the U.S.: $10 co-pay
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Routine physical exams
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$0 co-pay
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Skilled nursing facility care
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Days 1-120 in a facility: $40 co-pay
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Chiropractic services/ Acupuncture
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$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
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Vision services
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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
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Preventive and diagnostic services
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$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
X-rays
Lab services
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Outpatient prescription drugs** (see Formulary)
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$0 deductible
$0 co-pay for: Enalapril; Lisinopril (high blood pressure); Lovastatin; Simvastatin (high cholesterol); Glipizide; Glyburide; Metformin (diabetes)
Up to $9 co-pay for generic formulary drugs
Up to $40 co-pay for preferred brand drugs
30% coinsurance for specialty drugs
Up to $80 co-pay for non-preferred drugs
You pay up to $9 co-pay for generics or Medicare's discounted cost for generics (whichever is less) and receive Medicare's discount for brand drugs once your total drug spend reaches $2,930.
After you've spent $4,700 out-of-pocket: you will pay the greater of $2.60 and $6.50 co-pays or 5% coinsurance
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Dental benefit
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Once per year:
- one exam
- one set of x-rays
- one cleaning
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| Hearing aids benefit |
Up to $500 every year
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Out-of-pocket maximum for durable medical equipment
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Annual out-of-pocket max: $2,000
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* See
Plan Documents for benefit details.
**You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or your State Medicaid office.
In general, beneficiaries must use
network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Quantity limitations and restrictions may apply.
Last modified: October 1, 2011
H3811_MA4003_2012 CMS Approved 10/14/2011