Getting started with Samaritan Advantage Health Plan HMO

Welcome, Samaritan Advantage HMO members!

Samaritan Advantage Health Plan HMO is the locally managed Medicare plan for eligible residents of Linn, Benton and Lincoln County, Oregon. Member services and plan administration are provided by Samaritan Health Plans, a division of Samaritan Health Services. We’re proud to serve our friends and neighbors and contribute to the health and well-being of our community.

Your coverage information:
Conventional Plan | Premier Plan  | Premier Plan Plus  | Special Needs Plan 

List of covered drugs and pharmacies:
Premier Plan  | Premier Plan Plus  | Special Needs Plan 
Pharmacy Directory
2013 Formulary Prior Authorization requirements (PDF)
2013 Formulary Quantity Limits (PDF)
2013 Formulary Step Therapy Criteria (PDF)
 
Samaritan Advantage Health Plan HMO has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Quantity limitations and restrictions may apply.

Network providers:
List of Primary Care Providers 
List of Specialty Providers

Prior authorization:
Coverage of certain medical services and surgical procedures requires Samaritan Advantage Health Plans' written authorization before the services are performed.
2013 Prior Authorization List (PDF)
2012 Prior Authorization List  (PDF)

Do I qualify for extra help?
Low Income Subsidy

What are my rights as a member? 

FREE interpreter services
We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-832-4580. Someone who speaks your language can help you. This is a free service. See this information in another language. (PDF)

How to appoint a representative
You have the right to name a person to direct your health care when you cannot do so. This person is called your "health care representative". To appoint a representative for your Medicare benefits, both you and your representative must sign, date and complete one of these forms: You must send a copy to Samaritan Advantage Health Plan HMO each time you want the appointed representative to head any of your appeal requests within 60 days of the initial denial for the service requested. Once the form is received by Samaritan Advantage Health Plan HMO, it is considered current for one year. After one year has passed, you must complete a new form if you would like to continue the appointment of that representative.

Privacy Notice
Privacy notice (PDF)

                                  

Prescription drug forms

Prescription Exception or Coverage Determination: 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.

2012 Coverage Determination Request Form: 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.

2012 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: Use this form when you have a written prescription that you are mailing to Samaritan Health Services. 

Samaritan Pharmacy Services FAX Order Form: Provide this form to your physician to fax your prescription to Samaritan Health Services.

Samaritan Pharmacy Services Prescription Transfer Request: 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: We will cover your prescription at an out-of-network pharmacy under certain conditions.




Last modified: April 5, 2013
H3811_MA4001_2012E
CMS Approval Pending 

Your member forms

Request Electronic Funds Transfer (EFT) service: You have the option of paying your monthly premium through automatic withdrawal from your personal bank account.

Request reimbursement for medical or dental services: This form can be used to request reimbursement from our Plan for covered medical or dental services that you have paid for out-of-pocket. 

Designate your authorized representative: You have the right to name a person to direct your health care when you cannot do so. This person is called your "health care representative".

See instructions above on how to appoint a representative.

Appeal Request Form: This form can be used to request an appeal of a medical care coverage decision made by our plan.

Your member rights: This brochure provides information about your appeal rights under our plan.

Request for Health Plan Records: To speed up your request, this form is required by the Plan to be completed when you are requesting any Health Plan documentation from us.
Tell your Samaritan story | Contact Us | Terms of Use | Patient privacy
Samaritan Advantage Health Plan HMO is a coordinated care plan with a Medicare Advantage Contract and a contract with the Oregon Medicaid program. Individuals must have both Part A and Part B to enroll. Members may enroll in the Conventional, Premier, and Premier Plus plans only during specific times of the year. You must continue to pay your Medicare Part A and Part B premiums. You must receive all routine care from plan providers. Benefits, formulary, pharmacy network, premium, and/or co-payments/coinsurance may change on January 1 of each year. The benefit information provided is a brief summary, not a complete description of benefits. Limitations, co-payments and restrictions may apply. Other providers are available in our network. For more information, contact Samaritan Advantage Health Plan.

Other Medicare Links: By clicking on any of the following links, you will be leaving the Samaritan Health Plan website.
Centers for Medicare and Medicaid Services (CMS) at www.cms.hhs.gov Medicare at www.medicare.gov | The Office of the Medicare Ombudsman (OMO) at www.medicare.gov/navigation/help-and-support/ombudsman.aspx for assistance with complaints, grievances, and information requests | Medicare Complaint Form at www.medicare.gov/MedicareComplaintForm/home.aspx to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using this form | Social Security Administration (SSA) at www.ssa.gov
© 2012 Samaritan Health Services