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Samaritan Advantage Conventional Plan 

For those wanting the additional medical benefits of an Advantage plan without the Part D prescription drug benefit, we offer our Samaritan Advantage HMO Conventional Plan.

For more detailed benefit information, review our plan documents.

  Conventional Plan Benefits
Annual deductible $0 deductible
Medical Out-Of-Pocket Maximum $3,750 (The most you will pay per year for medical co-pays and coinsurance)
Doctor Office Visits $10 co-pay primary care visit
$20 co-pay specialist visit
Hospitalization $200 co-pay / day for days 1–5
$0 co-pay / day for days 6–90
$1,750 out-of-pocket maximum / year
Urgent Care – Nationwide $25 co-pay
Emergency Care – Worldwide $80 co-pay ($0 if you are admitted to the hospital within 12 hours)
Outpatient Surgery / Service $150 co-pay
Ambulatory Surgery Center $100 co-pay
Skilled Nursing Facility Care $0 co-pay / day for days 1–20 in a facility
$160 co-pay / day for days 21–60 in a facility
$0 co-pay / day for days 61–120 in a facility
Vision Services (Eyewear does not apply to annual medical
out-of-pocket maximum)
$20 co-pay for exams to diagnose and treat conditions and diseases of the eye
$20 co-pay for each routine eye exam; limited to 1 exam every year
Up to $125 for eye wear every year
Chiropractic / Acupuncture $20 co-pay for manual manipulation of the spine to correct subluxation
$25 co-pay for routine chiropractic with up to 5 visits / year
$20 co-pay per acupuncture visit with up to 30 visits / year
Routine Physical Exams $0 co-pay
Preventive and Diagnostic Services $0 co-pay for most services
(Refer to the plan’s Summary of Benefits for details.)
Premium $77 / month

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The Hometown Advantage

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H3811_MA4001-2019A, Page updated 10/1/2017