2012 Conventional Plan
Samaritan Advantage Conventional Plan HMO for 2012
CONVENTIONAL PLAN HMO
$67 month |
2012 BENEFIT HIGHLIGHTS* |
| Hospitalization |
Out-of-pocket limit: $1,500/year
$150/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
$50 co-pay for ambulance
|
| Urgent Care |
Anywhere in the U.S.: $10 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 |
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 |
NO.
Only available with the Premier Plan Plus HMO. |
| Hearing Aids Benefit |
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. |
* See 2012 Plan Documents for benefit details.
Last modified: October 24, 2012
H3811_MA4001_2012A CMS Approved October 24, 2012