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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