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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: Initial Coverage Phase (Most Medicare drugs are covered; mail order service is available; 1–3 month supply is available) |
Tier 1 (Preferred Generic): $3 or the full price of the drug, whichever is lower Tier 2 (Generic): $9 or the full price of the drug, whichever is lower Tier 3 (Preferred Brand): $47 or the full price of the drug, whichever is lower Tier 4 (Non-Preferred): 48% of the cost Tier 5 (Specialty): 33% of the cost Tier 6 (Select Care): $0 |
| Part D Prescription
Drug Limitations: Coverage Gap Phase (You enter this phase once you and your plan pay a combined total of $3,820.) |
Tier 1 (Preferred Generic): 37% of the cost Tier 2 (Generic): 37% of the cost Tier 3 (Preferred Brand): 25% of the cost, plus a portion of the dispensing fee Tier 4 (Non-Preferred): 37% of the cost for generic drugs; 25% of the cost for brand drugs, plus a portion of the dispensing fee Tier 5 (Specialty): 37% of the cost for generic drugs; 25% of the cost for brand drugs, plus a portion of the dispensing fee Tier 6 (Select Care): 37% of the cost for generic drugs |
| Part D Prescription Drug Limitations: Catastrophic Phase (You enter this phase once your yearly out-of-pocket drug costs total $5,100.) |
Generic: $3.40 of 5% of the cost, whichever is greater All Other: $8.50 of 5% of the cost, whichever is greater |
| 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_MA4001-7_2019A, Page updated 2/23/2019