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Samaritan Advantage Health Plans

Plan ID: H3811-1-0

Samaritan Advantage Valor (HMO)

2024 Samaritan Advantage Valor (HMO) H38110010 is a Medicare Advantage plan . It has received a 3-out-of-5 star rating from CMS for 2024.

Learn more about Samaritan Advantage Valor (HMO) H3811 - 001 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

3 / 5 stars for 2024

$5.00 /mo

Monthly premium

$0

Health deductible

$5200.00

Out-of-pocket maximum

Enroll online

Call to enroll

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Get personalized help from a licensed insurance agent
1-877-649-2073 TTY 711. 8am-11pm EST. 7 days a week!

Overview Icon

Plan Overview

2024 Samaritan Advantage Valor (HMO) H38110010 is a Local HMO offered in Benton, Lincoln and Linn counties by Samaritan Advantage Health Plans. It has a monthly premium of $5.00.

Premium Breakdown

Standard Part B Premium

$174.80

Part B premium reduction

$0

Part C Premium

$5.00

Monthly Premium (Parts C & D)

$5.00

Total Premium (Parts B, C, & D)

$169.90

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Special needs plan type

No

Out-of-pocket maximum

$5200.00

Plan Organization:

Samaritan Advantage Health Plans

Plan Type:

Local HMO

Location:

Benton, Lincoln and Linn counties

Drugs Covered:

No

Drug Formulary:

Pharmacies:

Doctor Choice:

Plan Doctors for Most Services

Doctors Link:

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Health deductible

$0

Sign up for Samaritan Advantage Valor (HMO)

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Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 TTY 711. 8am-11pm EST. 7 days a week

Drug Coverage Icon

Drug Coverage

Samaritan Advantage Valor (HMO) does not provide drug coverage. If drug coverage is something you need, you should consider shopping for other plans that do provide cost sharing on drugs.

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Additional Benefits

Samaritan Advantage Valor (HMO) also provides the following benefits.

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Comprehensive dental

Non-routine services
$0 copay
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Diagnostic services
$0 copay
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Restorative services
$0 copay
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Endodontics
$0 copay
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Periodontics
$0 copay
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Extractions
$0 copay
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Prosthodontics, other oral/maxillofacial surgery, other services
$0 copay
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Preventive dental

Oral exam
$0 copay
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Cleaning
$0 copay
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Fluoride treatment
$0 copay
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Dental x-ray(s)
$0 copay
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Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures
$5 copay
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Lab services
$5 copay
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Diagnostic radiology services (eg, MRI)
20% coinsurance
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Outpatient x-rays
$15 copay
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Doctor visits

Primary
$10-20 copay per visit
Specialist
$35-45 copay per visit
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Emergency care/Urgent care

Emergency
$100 copay per visit (always covered)
Urgent care
$35 copay per visit (always covered)
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Foot care (podiatry services)

Foot exams and treatment
$35 copay
Routine foot care
Not covered
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Ground ambulance

Service
$250 copay
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Hearing

Hearing exam
$40 copay
Fitting/evaluation
Not covered
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Hearing aids - inner ear
Not covered
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Hearing aids - outer ear
Not covered
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Hearing aids - over the ear
Not covered
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Inpatient hospital coverage

Service
Tier 1 $375 per day for days 1 through 5 $0 per day for days 6 through 90 Tier 2 $450 per day for days 1 through 5 $45 per day for days 6 through 60 $0 per day for days 61 through 90
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Outpatient hospital coverage

Service
$35-475 copay per visit
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Outpatient prescription drugs

Samaritan Advantage Valor (HMO) does not provide this type of benefit.

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Optional benefits

Samaritan Advantage Valor (HMO) does not provide this type of benefit.

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Medical equipment/supplies

Durable medical equipment (eg, wheelchairs, oxygen)
20% coinsurance per item
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Prosthetics (eg, braces, artificial limbs)
20% coinsurance per item
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Diabetes supplies
$0 copay
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Medicare Part B drugs

Chemotherapy
0-20% coinsurance
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Other Part B drugs
0-20% coinsurance
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Part B Insulin drugs
0-20% coinsurance (up to $35)
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Mental health services

Inpatient hospital - psychiatric
$500 per stay
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Outpatient group therapy visit with a psychiatrist
$20 copay
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Outpatient individual therapy visit with a psychiatrist
$20 copay
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Outpatient group therapy visit
$20 copay
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Outpatient individual therapy visit
$20 copay
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Preventive care

Service
$0 copay
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Rehabilitation services

Occupational therapy visit
$30 copay
Physical therapy and speech and language therapy visit
$30 copay
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Skilled Nursing Facility

Service
$0 per day for days 1 through 20 $180 per day for days 21 through 45 $0 per day for days 46 through 100
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Transportation

Service
$0 copay
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Vision

Routine eye exam
$20 copay
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Other
Not covered
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Contact lenses
$0 copay
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Eyeglasses (frames and lenses)
$0 copay
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Eyeglass frames
$0 copay
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Eyeglass lenses
$0 copay
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Upgrades
$0 copay
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Wellness programs (eg, fitness, nursing hotline)

Service
Covered
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Get Personalized Help from a licensed insurance agent

1-877-649-2073 TTY 711. 8am-11pm EST. 7 days a week

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