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Medical and Prescription Drug Plan with More Benefits

For those wanting the additional medical benefits of an Advantage plan as well as Part D prescription drug coverage, consider our Premier Plan HMO. This plan includes additional benefits like a SamFit gym membership and comprehensive dental services.

  Premier Plan Plus 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 15% of the cost
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
$35 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: 50% 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 will pay whichever is less for generics: maximum $9 for generics or Medicare’s discounted cost for generics.
You receive Medicare’s discount for 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.
Dental services
(Does not apply to annual medical out-of-pocket maximum; choose any dentist that accepts Medicare Advantage plans)
$25 per exam (up to 2 oral exams with regular cleanings/year)
$0 per visit for dental X-rays (1 per year)
$1,000 comprehensive dental
Gym Membership $0 gym membership to SamFit
Hearing Aids and Equipment
(Does not apply to annual medical out-of-pocket maximum)
Up to $500 per year
Premium $129 / month

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

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