Samaritan Advantage Health Plans
Plan ID: H3811-3-0
2024 Samaritan Dual Advantage (HMO D-SNP) H3811 — 003— 0 is a Medicare Advantage plan with drug coverage. It has received a 3-out-of-5 star rating from CMS for 2024.
Learn more about Samaritan Dual Advantage (HMO D-SNP) H3811 - 003 - 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
$40.60 /mo
Monthly premium
Coming soon
Health deductible
$545.00
Drug deductible
$0
Out-of-pocket maximum
Enroll online
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1-877-649-2073 TTY 711. 8am-11pm EST. 7 days a week!
2024 Samaritan Dual Advantage (HMO D-SNP) H3811 — 003— 0 is a HMO offered in Benton, Linn and Lincoln counties by Samaritan Advantage Health Plans. It has a monthly premium of $40.60.
Important:
2024 Samaritan Dual Advantage (HMO D-SNP) H3811 — 003 — 0 is a Dual-Eligible Special Needs Type plan. You can only enroll in this plan if you meet specific criteria.
Standard Part B Premium
$174.80
Part B premium reduction
$0
Part C Premium
$0
Part D Basic Premium
$40.60
Part D Supplemental Premium
$0
Part D Total
$40.60
Monthly Premium (Parts C & D)
$40.60
Total Premium (Parts B, C, & D)
$205.50
Special needs plan type
Yes
Out-of-pocket maximum
$0
Conditions Covered
None
Plan Organization:
Samaritan Advantage Health Plans
Plan Type:
HMO
Location:
Benton, Linn and Lincoln counties
Drugs Covered:
Yes
Drug Formulary:
Pharmacies:
Doctor Choice:
Plan Doctors for Most Services
Doctors Link:
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Health deductible
Coming soon
Drug deductible
$545
Note:
This plan does not charge an annual deductible for all drugs. The $545.00 annual deductible only applies to drugs in certain tiers.
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 TTY 711. 8am-11pm EST. 7 days a week
Samaritan Dual Advantage (HMO D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Benefit Type
Defined Standard Benefit
Prescription drug deductible
$545.00
Increased initial coverage limit
No
Additional gap coverage
No
This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.
Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
---|---|---|---|---|
$40.60 | $40.60 | $40.60 | $40.60 | $40.60 |
After you pay your $545.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Preferred Pharmacy | Standard Pharmacy | Preferred Mail | Standard Mail |
---|---|---|---|---|
1. Preferred Generic | - | 25% | - | - |
2. Standard Generic | - | - | - | - |
3. Preferred Brand | - | - | - | - |
4. Non-Preferred Drug | - | - | - | - |
5. Specialty Tier | - | - | - | - |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
Generic Drugs
$4.15 copay or 5% (whichever costs more)
Brand-name
$10.35 copay or 5% (whichever costs more)
Samaritan Dual Advantage (HMO D-SNP) also provides the following benefits.
Samaritan Dual Advantage (HMO D-SNP) does not provide this type of benefit.
Samaritan Dual Advantage (HMO D-SNP) does not provide this type of benefit.
SMID: MULTIPLAN_HCIHNMEDADVRX24_M
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