2012 Part D

2012 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.

2012 MEDICARE PART D BENEFIT HIGHLIGHTS *
Plan Name

Premier Plan HMO

Premier Plus Plan HMO
Premium

$99

$121
Part D Prescription Drugs ** (see Formulary)

$0 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 $2,930.

After you've spent $4,700 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 $2,930.

After you've spent $4,700 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
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.
By clicking this link, you will be leaving the Samaritan Health Plan website.

* See Summary of Benefits for a complete listing of benefits and Formulary for the list of covered drugs under 2012 Plan Documents.

 

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.
By clicking this link, you will be leaving the Samaritan Health Plan website.

The following chart outlines the premium amounts based on the various low income subsidy levels.

 

2012 Monthly Premiums Conventional Plan $67/month Premier Plan $99/month Premier Plan Plus $121/month
25% Low Income Subsidy (LIS)

N/A

 You pay $93.30* You pay $112.80*
50% Low Income Subsidy (LIS)

N/A

 You pay $87.70* You pay $104.50*
75% Low Income Subsidy (LIS)

N/A

 You pay $82.00* You pay $96.30*
100% Low Income Subsidy (LIS)

N/A

 You pay $76.40* You pay $88.10*
* 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 and Medicaid Services (CMS) Best Available Evidence Policy at CMS Best Available Evidence Policy.
By clicking this link, you will be leaving the Samaritan Health Plan website.

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 24, 2012
H3811_MA4001_2012A CMS Approved October 24, 2012

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Tell your Samaritan story | Contact Us | Terms of Use | Patient privacy
Samaritan Advantage Health Plan HMO is a coordinated care plan with a Medicare Advantage Contract and a contract with the Oregon Medicaid program. Individuals must have both Part A and Part B to enroll. Members may enroll in the Conventional, Premier, and Premier Plus plans only during specific times of the year. You must continue to pay your Medicare Part A and Part B premiums. You must receive all routine care from plan providers. Benefits, formulary, pharmacy network, premium, and/or co-payments/coinsurance may change on January 1 of each year. The benefit information provided is a brief summary, not a complete description of benefits. Limitations, co-payments and restrictions may apply. Other providers are available in our network. For more information, contact Samaritan Advantage Health Plan.

Other Medicare Links: By clicking on any of the following links, you will be leaving the Samaritan Health Plan website.
Centers for Medicare and Medicaid Services (CMS) at www.cms.hhs.gov Medicare at www.medicare.gov | The Office of the Medicare Ombudsman (OMO) at www.medicare.gov/navigation/help-and-support/ombudsman.aspx for assistance with complaints, grievances, and information requests | Medicare Complaint Form at www.medicare.gov/MedicareComplaintForm/home.aspx to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using this form | Social Security Administration (SSA) at www.ssa.gov
© 2012 Samaritan Health Services