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.
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: $2.60 and $6.50 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: $2.60 and $6.50 co-pays or 5% coinsurance
|
Premier 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
Out-of-network coverage
Getting prescriptions when you travel
Mail order drugs
Low income subsidy
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.
* See Summary of Benefits for a complete listing of benefits and Formulary for the list of covered drugs under Member resources.
**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 1, 2011
H3811_MA4003_2012 CMS Approved 10/14/2011