How much will I pay for my drugs?

How much will I pay for my drugs?


More benefits, better value
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.

2013 MEDICARE PART D BENEFIT HIGHLIGHTS

Premier Plan HMO

Premier Plus Plan HMO

Premium

$105

$135

Part D Prescription Drugs*

See
Are my drugs covered? for list of covered drugs (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 $2,970.

After you've spent $4,750 out-of-pocket, you will pay the greater of: $2.65 and $6.60 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 $2,970.

After you've spent $4,750 out-of-pocket, you will pay the greater of: $2.65 and $6.60 co-pays or 5% coinsurance


For full details on your medical coverage see: Evidence of Coverage under your plan page.

*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.

Last modified: October 1, 2012
H3811_MA4001_2012A CMS Approved October 24, 2012