2011 Part D prescription drug benefits
Samaritan Advantage’s Premier and Premier Plus HMO Plans, combine a prescription drug plan with a medical benefits package that covers more than original Medicare with less out-of-pocket expense for you.
2011 MEDICARE PART D BENEFIT HIGHLIGHTS *
| Plan Name |
Premier Plan HMO
|
Premier Plus Plan HMO
|
| Premium |
$99
|
$122
|
| Part D Prescription Drugs ** (see Formulary) |
$110 deductible
$0 co-pay for:
-
Enalapril and Lisinopril (high blood pressure)
-
Lovastatin, Simvastatin (high cholesterol)
-
Glipizide, Glyburide, Metformin (diabetes)
Up to $9 co-pay generic
Up to $40 co-pay preferred brand
Up to $80 co-pay non-preferred
30% coinsurance specialty
|
|
Gap Coverage
|
NO ADDITIONAL COVERAGE
You receive Medicare's discount for generics and brand drugs once your total drug spend reaches $2,840.
After you've spent $4,550 out-of-pocket, you will pay the greater of: $2.50 and $6.30 co-pays or 5% coinsurance |
EXTRA COVERAGE FOR GENERICS
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 $2,840.
After you've spent $4,550 out-of-pocket, you will pay the greater of: $2.50 and $6.30 co-pays or 5% coinsurance
|
Premier Plan and Premier Plan Plus include these additional MEDICAL benefits:
- Routine physical and preventative exams
- Routine vision services, including glasses
- Routine chiropractic services
- Worldwide coverage for emergency services and nationwide coverage for urgent care services
- Acupuncture
- Hearing exams
- Health and wellness education services and classes
- Hearing aid benefit (Premier Plan Plus ONLY)
- Dental benefits (Premier Plan Plus ONLY)
- Extra coverage for generic drugs through Medicare’s coverage gap (Premier Plan Plus ONLY)
Samaritan Advantage Health Plan HMO has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area.
Other important information regarding Samaritan Advantage Health Plan's HMO prescription drug coverage:
Formulary (List of Covered Drugs)
Pharmacy Directory
Out-of-network coverage
Getting prescriptions when you travel
Mail order drugs
Member rights (grievances and appeals)
To obtain an aggregate number of appeals and grievances for Samaritan Advantage Health Plan HMO, go to www.medicare.gov:
- Select “Learn More About Plans In Your Area”
- Then select your “State” and “Continue”
- Then select your county in “Select a county” and “Continue”
- From the page “Plans in Your Area” under “Review List of Plans”, select “Get Plan Performance Information” and find Samaritan Advantage’s plans
For additional help, try the Medicare Prescription Drug Plan Finder on www.medicare.gov.
* See Summary of Benefits for a complete listing of benefits and Formulary for the list of covered drugs under Member resources.
Low income subsidy
If you qualify for extra help with your Medicare prescription drug plan costs, your premium and costs at the pharmacy will be lower. When you join one of our plans, Medicare will tell us how much extra help you are getting. Then we will let you know the amount you will pay.
How to inquire about Low Income Subsidy
If you are not getting this extra help, you can see if you qualify by calling Social Security at 1-800-772-1213 (TTY users should call 1-800-325-0778) or visit www.socialsecurity.gov on the Web.
The following chart outlines the premium amounts based on the various low income subsidy levels.
| 2011 Monthly Premiums |
Conventional Plan $67/month |
Premier Plan $99/month |
Premier Plan Plus $122/month |
| 25% Low Income Subsidy (LIS) |
N/A
|
You pay $95.40*** |
You pay $116.60*** |
| 50% Low Income Subsidy (LIS) |
N/A
|
You pay $91.70*** |
You pay $111.10*** |
| 75% Low Income Subsidy (LIS) |
N/A
|
You pay $88.10*** |
You pay $105.70*** |
| 100% Low Income Subsidy (LIS) |
N/A
|
You pay $84.50*** |
You pay $100.30*** |
***The premiums listed above include both medical service and prescription drug benefits. These premiums do not include any Medicare Part B premium you may have to pay.
See also Centers for Medicare & Medicaid Services (CMS)
Best Available Evidence Policy
In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Quantity limitations and restrictions may apply.
Formulary
A formulary is a list of drugs selected by Samaritan Advantage Health Plan HMO in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other plan rules are followed.
Go here to view or download the 2010 Samaritan Advantage Health Plan HMO Formulary documents.
Member Rights
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. See Member Resources for information about how to file a complaint or request a non-formulary medication or obtain a medication prior authorization.
Last modified: October 1, 2010
H3811_MA4002 CMS Approved 10.22.2010