Prescription drug forms
Prescription Exception or Coverage Determination
(PDF): If you are a provider, you can use this form to ask us to make a coverage determination for a prior authorized medication or a medication exception to our coverage rules if the member is on one of our plans that offer prescription drug coverage.
Drug Coverage Determination Request Form
(PDF): If you are a member of one of our Part D plans, or an authorized representative, you can use this form to ask us to make a medication exception to our coverage rules.
Redetermination Request Form
If we deny your request for coverage of (or payment for) a prescription drugs, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. This form may be sent to us by mail or fax:
Address: Samaritan Advantage Health Plan HMO , P.O. Box M, Corvallis, OR 97339
Fax Number: (541) 768-6288
Expedited redeterminations (appeals) requests can by made by phone at (541) 768-4550
or toll free at 1-800-832-4580
Prescription Mail Order
(PDF): Use this form when you have a written prescription that you are mailing to Samaritan Health Services.
Samaritan Pharmacy Services FAX Order Form
(PDF): Provide this form to your physician to fax your prescription to Samaritan Health Services.
Samaritan Pharmacy Services Prescription Transfer Request
(PDF): Use this form to conveniently transfer all your prescriptions to Samaritan Health Services. We will contact the pharmacies you list on the form for you and have the prescriptions transferred.
Prescription Reimbursement Form
(PDF): We will cover your prescription at an out-of-network pharmacy under certain conditions.
Last modified: Oct. 1, 2015 H3811_MA4001_2016A
CMS approved 10/15/2015