2012 Premier Plan

Samaritan Advantage Premier Plan HMO for 2012

PREMIER PLAN HMO
$99 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

X-rays

Lab services

Outpatient prescription drugs** (see Formulary)

$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 receive a discount on brand name drugs and pay 93% of the plan's costs for all generic 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

Dental benefit

NO.

Only available with Premier Plan Plus HMO

Hearing aids benefit

NO.

Only available with Premier Plan Plus HMO

Out-of-pocket maximum for durable medical equipment

NO.

Only available with Premier Plan Plus HMO


* 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 24, 2012
H3811_MA4001_2012A CMS Approved October 24, 2012

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