Samaritan Advantage Premier Plan Plus (HMO) Plan Details for Benton County, OR
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*CMS rated this Samaritan Advantage Health Plans plan (H3811-009-0) 3 (Average) out of 5 stars.
Samaritan Advantage Premier Plan Plus (HMO) is a Medicare Advantage plan with a prescription drug plan. The 2025 Annual Enrollment period starts October 15. Plan benefits begin Ja
See more Medicare Advantage Plans in Benton County, Oregon.
Samaritan Advantage Premier Plan Plus Basic Details
| Plan Basics | |
|---|---|
| Plan ID: | H3811-009-0 |
| Plan Type: | HMO |
| Plan Year: | 2025 |
| Premium: | $138.00/mo Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 3,750.00 /yr |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Enhanced, $0.00 deductible |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Benton County, OR |
| Insured By: | Samaritan Advantage Health Plans |
| Summary of Benefits |
|---|
Samaritan Advantage Health Plans Out-of-Pocket Costs
This Samaritan Advantage Health Plans Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H3811-009-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
| Healthcare Service | Member Cost |
|---|---|
| Doctor Visits (In-Network) | |
| Primary: | $0 |
| Specialist: | $15 Copay Prior Authorization Required |
| Preventive care: | $0 |
| Foot Care (In-Network) | |
| Foot exams and treatment (Medicare-covered): | $35 Copay |
| Routine foot care: | Not Covered |
| Chiropractic Care (In-Network) | |
| Medicare-covered chiropractic care: | $20 Copay |
| Routine chiropractic care: | Not Covered |
| Emergency Care / Urgent Care | |
| Emergency room care: | $90 Copay |
| Urgent care: | $35 Copay |
| Ground ambulance: | $250 Copay |
| Inpatient hospital coverage: | $325.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
| Outpatient hospital coverage: | $250 Copay Prior Authorization Required |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $165.00 per day for days 21 through 45 $0.00 per day for days 46 and beyond |
| Optional supplemental benefits: | |
| Mental Health Services (In-Network) | |
| Outpatient individual therapy visit with a psychiatrist: | $0 |
| Outpatient group therapy visit with a psychiatrist: | $0 |
| Inpatient hospital - psychiatric: | $1,000.00 per stay |
| Outpatient group therapy visit: | $0 |
| Outpatient individual therapy visit: | $0 |
| Rehabilitation Services (In-Network) | |
| Physical therapy and speech and language therapy visit: | $25 Copay |
| Occupational therapy visit: | $25 Copay |
| Medical Equipment / Supplies (In-Network) | |
| Diabetes supplies: | $0 |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Prior Authorization Required |
| Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
| Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
| Diagnostic radiology services (e.g., MRI): | 20% Coinsurance Prior Authorization Required |
| Lab services: | $0 |
| Outpatient x-rays: | $10 Copay Prior Authorization Required |
| Diagnostic tests and procedures: | $0 |
| Medicare Part B Drugs (In-Network) | |
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Samaritan Advantage Premier Plan Plus Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits Samaritan Advantage Health Plans includes with this plan:
| Supplemental Healthcare Service | Member Cost |
|---|---|
| Preventive Dental | |
| Oral exam (In-Network) | Not Covered |
| Fluoride treatment (In-Network) | Not Covered |
| Dental x-ray(s) (In-Network) | Not Covered |
| Cleaning (In-Network) | Not Covered |
| Comprehensive Dental | |
| Periodontics (In-Network) | Not Covered |
| Non-routine services (In-Network) | Not Covered |
| Diagnostic services (In-Network) | Not Covered |
| Extractions (In-Network) | Not Covered |
| Endodontics (In-Network) | Not Covered |
| Restorative services (In-Network) | Not Covered |
| Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
| Hearing Aids | |
| Fitting/evaluation (In-Network) | Covered Limits may apply |
| Hearing aids (In-Network) | Not Covered |
| Hearing exam (In-Network) | Not Covered |
| Vision | Maximum vision benefit: | $2.00 Every three years |
| Eyeglasses (frames and lenses) (In-Network) | Not Covered |
| Routine eye exam (In-Network) | $5 Copay |
| Contact lenses (In-Network) | Not Covered |
Prescription Drug Plan Costs & Benefits
Samaritan Advantage Premier Plan Plus includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans offer greater coverage than basic plans, typically providing lower cost-sharing, broader drug coverage, and additional benefits, such as covering drugs not included in the standard formulary. These plans usually have higher premiums due to the extra coverage and flexibility they provide, but they cover a larger percentage of overall drug costs.
As of 2023, approximately 75% of people on Medicare are enrolled in enhanced plans.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. LIS, also known as Extra Help, is a Social Security program that helps people with limited income and resources lower or cut Part D costs.
The following table outlines the premium details of this prescription drug plan.
| Basic Part D Premium: | $0.00 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $0.00 |
| Low Income Premium Subsidy: | $26.15 |
| Low Income Premium Subsidy CMS Pays: | $0.00 |
| Low Income Subsidy Premium: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $0.00. You must pay this amount at the pharmacy before Samaritan Advantage Health Plans begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Samaritan Advantage Premier Plan Plus has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order | Out of Network |
|---|---|---|---|
| Preferred Generic | $3.00 | $0.00 | $13.00 |
| Generic | $12.00 | $0.00 | $20.00 |
| Preferred Brand | $40.00 | $0.00 | $47.00 |
| Non-Preferred Drug | 50.00% | 0.00% | 50.00% |
| Specialty Tier | 33.00% | 0.00% | 33.00% |
| Select Care Drugs | $0.00 | $0.00 | $0.00 |
| *The Part D deductible does not apply. | |||
CMS 5-Star Rating Marks
The following table shows the quality ratings for this Samaritan Advantage Health Plans plan. Each year CMS rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories using a 5-star rating system. Here are the most recent ratings for Samaritan Advantage Premier Plan Plus .
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact Samaritan Advantage Health Plans
| Plan Website: | http://www.samhealthplans.org/shop-samaritan-plans/medica |
|---|---|
| Formulary Information: | https://medicare.samhealthplans.org |
| Pharmacy Information: | Samaritan Advantage Health Plans Pharmacy Page |
| Prospective Members: | (800)207-3182 |
| TTY Users: | (800)735-2900 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Citations & References
- Samaritan Advantage Health Plans, http://www.samhealthplans.org/shop-samaritan-plans/medica, Last Accessed February 20, 2024
- Medicare.gov, "Your health plan options", Last Accessed February 20, 2024
- Medicare.gov, "How Original Medicare Works", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You Handbook", Last Accessed February 19, 2024
- Medicare.gov, "What Medicare Covers", Last Accessed February 7, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.