Premier Plan for 2013

Samaritan Advantage Premier Plan HMO for 2013

Samaritan Advantage Premier Plan HMO provides generous medical benefits plus Medicare Part D prescription drug coverage for Corvallis, Albany, Lebanon, Sweet Home, Newport, Lincoln City and cities throughout Linn, Benton, and Lincoln County, Oregon.

Below you will find coverage information for Samaritan Advantage Premier Plan HMO. These materials are important documents that describe your health insurance benefits in detail.

2013 Summary of Benefits
Premier Plan (PDF) CMS Approved

2013 Evidence of Coverage 
Premier Plan  (PDF) CMS Approved

2013 Prescription Drug Benefits 
Premier Plan Formulary
Premier Plan Pharmacy Directory
Samaritan Advantage Health Plan HMO has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area.

$105 month


Out-of-pocket limit: $1,750/year

$185/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

$100 co-pay for ambulance

Urgent Care Anywhere in the U.S.: $25 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


Pap smears

Pelvic exams

Prostate cancer screening

Diagnostic tests


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 79% of the plan's costs for all generic 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

Dental benefit


Only available with Premier Plan Plus HMO

Hearing aids benefit


Only available with Premier Plan Plus HMO

Out-of-pocket maximum for durable medical equipment


Only available with Premier Plan Plus HMO

**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.

Are my drugs covered?
In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Quantity limitations and restrictions may apply.

What are my rights as a member?
As a member of Samaritan Advantage Health Plan HMO you have the right to make a complaint if you have concerns or problems related to your coverage or care or ask us to cover a specific medical service. Read What are my rights as a member? for additional information.

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