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Medical Plan with a Gym Membership and Preventive Dental

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.

  Conventional Plan Benefits
Deductible $0 annual deductible
Medical Out-Of-Pocket Maximum $3,750 (The most you will pay per year for medical.)
Doctor Office Visits $5 per primary care visit
$20 per specialist visit
Hospitalization $200 per day for days 1–5
$0 after day 5
$1,750 maximum out-of-pocket for inpatient hospital care
Urgent Care – Nationwide $25 per urgent care visit
Emergency Care – Worldwide $90 per emergency care visit ($0 if you are admitted to the hospital within 12 hours)
Ambulance $250 per one-way trip by ground
Air Ambulance 20% of the cost
Outpatient Surgery / Service $150 per outpatient hospital services and observation services
$100 per ambulatory surgical services
Skilled Nursing Facility Care $0 per day for days 1–20 in a facility
$160 per day for days 21–60 in a facility
$0 per day for days 61–120 in a facility
Vision Services (Eyewear does not apply to annual medical
out-of-pocket maximum)
$20 for exams to diagnose and treat conditions and diseases of the eye
$20 per routine eye exam (1 per year)
$125 for eye wear per year
Chiropractic $20 per visit for manual manipulation of the spine to correct subluxation
$25 per visit routine chiropractic with up to 5 visits / year
Acupuncture $20 per acupuncture visit with up to 30 visits per year
Routine Physical Exams $0 per exam
Preventive and Diagnostic Services $0 per visit for most services
(See the Evidence of Coverage for details.)
Preventive Dental — Choose any dentist that accepts Medicare Advantage plans  $20 per exam (up to 2 oral exams with regular cleanings/year)
$0 per visit for dental X-rays (1 per year)
Gym Membership $0 gym membership to SamFit
Premium $70 / month

For more detailed benefit information, review the plan documents for the Conventional Plan:

2019 Summary of Benefits 
2019 Annual Notice of Changes
2019 Evidence of Coverage

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H3811_MA4001-2_2019A, Page updated 11/24/2018