2017 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Samaritan Advantage Premier Plan Plus (HMO) | ||||
Location: | Lincoln, Oregon Click to see other locations | ||||
Plan ID: | H3811 - 009 - 0 Click to see other plans | ||||
Member Services: | 1-800-832-4580 TTY users 1-800-735-2900 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Samaritan Advantage Premier Plan Plus (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $140.00 (see Plan Premium Details below) | ||||
Annual Deductible: | $0 (Tier excluded from the Deductible.) | ||||
Annual Initial Coverage Limit (ICL): | $3,700 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,750 | ||||
Additional Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 4,304 drugs | Browse the Samaritan Advantage Premier Plan Plus (HMO) Formulary | |||
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $3.00 | $9.00 | $47.00 | 45% | 33% |
• Number of Drugs per Tier: | 58 | 1988 | 279 | 1173 | 806 |
Plan's Pharmacy Search: | http://www.samhealth.org/Medicare | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in (H3811 - 009): | 1,577 members | ||||
Plan’s Summary Star Rating: | 3.5 out of 5 Stars. | ||||
• Customer Service Rating: | 3 out of 5 Stars. | ||||
• Member Experience Rating: | 3 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 4 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part C Premium | Part D Base Premium | Part D Supplemental Premium | |
$140.00 | $70.90 | $69.10 | $0.00 | ||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
Total Monthly Premium with LIS (Parts C & D): | $70.90 | $70.90 | $70.90 | $70.90 | |
— Plan Health Benefits — | |||||
** General Plan Information ** | |||||
Choice of Doctors?: Information Not Available | |||||
** Cost ** | |||||
Monthly Health Plan Premium: Information Not Available | |||||
Monthly Drug Plan Premium: Information Not Available | |||||
Health Plan Deductible: Information Not Available | |||||
Other Health Plan Deductibles?: Information Not Available | |||||
Maximum Out-of-Pocket Enrollee Responsibility (does not include prescription drugs) : Information Not Available | |||||
** Extra Benefits ** | |||||
Prescription Drugs Covered?: Information Not Available | |||||
Optional Supplemental Benefits?: Information Not Available | |||||
** Outpatient Care and Services ** | |||||
Ambulance Services: Information Not Available | |||||
Dialysis: Information Not Available | |||||
Doctor Office Visits: Information Not Available | |||||
Specialist Office Visit: Information Not Available | |||||
Durable Medical Equipment: Information Not Available | |||||
Emergency Care: Information Not Available | |||||
Home Health Care: Information Not Available | |||||
Outpatient Hospital Services: Information Not Available | |||||
** Preventive Care ** | |||||
Physical Exams: Information Not Available | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care (Acute): Information Not Available | |||||
Optional Supplemental Benefits?: Information Not Available | |||||
Skilled Nursing Facility (SNF): Information Not Available | |||||
Prescription Drugs Covered?: Information Not Available | |||||
** Outpatient Care ** | |||||
Dialysis: Information Not Available | |||||
** Additional Benefits ** | |||||
Optional Supplemental Benefits?: Information Not Available |