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Plan H3811-009-0: Samaritan Advantage Premier Plan Plus (HMO) – 2025 Coverage Details for Linn County, OR

This page provides coverage, cost, and availability details for Samaritan Advantage Health Plans’s H3811-009-0 Medicare Advantage plan for 2025.

See more Medicare Advantage Plans in Linn County, Oregon.

CMS 2025 Rating: ☆☆☆☆☆*

*CMS rated this Samaritan Advantage Health Plans plan (H3811-009-0) 3 (Average) out of 5 stars.

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system. The Samaritan Advantage Health Plans logo is a registered trademark.[2] Its use by MedicareWire is strictly for editorial purposes. This is not a solicitation of insurance.

Samaritan Advantage Premier Plan Plus Basic Plan Details

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 (in-network)
Part B Reduction
$0.00/mo
Drug Plan Benefit
Enhanced, $0.00 deductible
Supplemental Benefits
Vision, Hearing
Availability
Linn County, OR
Insured By
Samaritan Advantage Health Plans
Summary of Benefits

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Health Plan 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.

Doctor's Office Visits

Primary
Not Covered
Specialist
$15 Copay
Prior Authorization Required

Emergency, Urgent, and Inpatient Hospital Coverage

Emergency room care
$90 Copay
Urgent care
$35 Copay
Ground ambulance
$250 Copay
Inpatient hospital care
$325.00 per day for days 1 through 5
$0.00 per day for days 6 and beyond
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

Foot Care

Foot Exams and Treatments (Medicare-covered)
$35 Copay
Routine Foot Care
Not Covered

Chiropractic Care

Medicare-covered chiropractic
$20 Copay
Routine chiropractic
Not Covered

Mental Health Services

Outpatient individual therapy
Not Covered
Outpatient group therapy
Not Covered
Inpatient psychiatric hospital care
$1,000.00 per stay

Rehabilitation Services

Physical therapy and speech and language therapy
$25 Copay
Occupational therapy
$25 Copay

Medical Equipment and Supplies

Diabetes supplies
Not Covered
Durable medical equipment
20% Coinsurance
Prior Authorization Required
Prosthetics
20% Coinsurance

Diagnostics, Lab Services, and Imaging

Diagnostic radiology services
20% Coinsurance
Prior Authorization Required
Lab services
Not Covered
Outpatient x-rays
$10 Copay
Prior Authorization Required
Diagnostic tests and procedures
Not Covered

Medicare Part B Drugs

Chemotherapy
20% Coinsurance
Other Part B drugs (Medicare-covered)
20% Coinsurance

Dental Services

Medicare Covered Preventive Dental
$20 Copay
Prior Authorization Required
Oral exam
$0
Dental x-rays
$0
Cleaning
$0
Periodontics
Not Covered
Endodontics
Not Covered
Restorative Services
Not Covered
Maximum dental benefit
$2,750.00 (Every year)

Hearing Aids and Services

Fitting/evaluation
Covered
Limits may apply
Hearing aids
Not Covered
Hearing exam
Not Covered

Vision Services

Medicare-covered eye exam
$ to $25 Copay
Routine eye exam
$ to $5 Copay
1 Every year
Eyewear benefits
None

Get a copy of the Samaritan Advantage Premier Plan Plus Summary of Benefits.

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Do you have questions about costs in this plan? Call 1-855-728-0510 (TTY 711) to speak with a licensed insurance agent and learn more about this plan and other plans on this site (Mon-Fri 5am-6pm, Sat 6am-5pm PT).

Prescription Drug Costs & Benefits

Samaritan Advantage Premier Plan Plus includes enhanced benefit Medicare Part D. Enhanced benefits offer greater coverage than basic, 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 Premium with Extra Help

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 premium assistance details with Extra Help.

Low Income Premium Subsidy:${part_d_lips_amount}
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 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 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
Preferred Generic$3.00$0.00
Generic$12.00$0.00
Preferred Brand$40.00$0.00
Non-Preferred Drug50.00%0.00%
Specialty Tier33.00%0.00%
Select Care Drugs$0.00$0.00
*The Part D deductible does not apply.

Citations & References

Research Note: This content is based on independent analysis of CMS data by David Bynon, Medicare analyst and founder of MedicareWire.

For details on how this plan was analyzed and constructed using CMS data, see our Medicare Plan Research Methodology.

Disclaimer: MedicareWire does not endorse or rank Medicare plans. Plan information is provided for educational and research purposes only and may not reflect the most current data available from CMS or the plan provider.