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2019 Premier Plan
Medical and Prescription Drug Plan
For those wanting the additional medical benefits of an Advantage plan as well as Part D prescription drug coverage, consider our Premier Plan HMO. If you are interested in additional benefits, such as a SamFit gym membership and dental services, see our Premier Plan Plus.
| Premier 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 | $15 per primary care visit $35 per specialist visit |
| Hospitalization | $300 per day for days 1–6 $0 after day 6 $1,750 maximum out-of-pocket for inpatient hospital care |
| Urgent Care – Nationwide | $35 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 | $200 per outpatient surgery |
| 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) |
$35 for exams to diagnose and treat conditions and diseases of the eye $0 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.) |
| Part D Prescription Drug Deductible | $0 annual deductible |
| Part D Prescription
Drug Benefits (Most Medicare drugs are covered; mail order service is available; 1–3 month supply is available) |
Tier 1: Maximum $3 for 7 drugs:
High blood pressure (Enalapril, Lisinopril)
High cholesterol (Lovastatin, Simvastatin)
Diabetes (Glipizide, Glyburide, Metformin)
Tier 2: Maximum $9 for generic formulary drugs Tier 3: Maximum $47 for preferred brand drugs Tier 4: 48% of the cost for non-preferred brand drugs Tier 5: 33% of the cost for specialty drugs Tier 6: $0 Select Care Drugs (Diabetic drugs) |
| Part D Prescription Drug Limitations | Once your total drug spend reaches $3,820, you receive Medicare’s discount for generics and brand drugs.
After you have spent $5,100 out-of-pocket, you will pay the greater of: $3.40 and $8.50 or 5% of the cost. |
| Premium | $100 / month |
For more detailed benefit information, review the plan documents for the Premier Plan:
2019 Summary of Benefits
2019 Annual Notice of Changes
2019 Evidence of Coverage
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Are My Doctors, Specialists and Prescriptions Covered?
Stay in the Samaritan family or choose any doctor or specialist in our extensive network. Learn which prescriptions are covered, which pharmacies are in our network, how to fill prescriptions when travelling, and more.
H3811_MA4001-2019A, Page updated 10/1/2018