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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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H3811_MA4001-7_2019A, Page updated 2/23/2019