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

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