2011 Plan Documents
2011 Plan documents
Here you can download Samaritan Advantage Health Plan HMO documents. You will need Adobe Acrobat Reader in order to view the files.
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2011 Summary of Benefits
Conventional Plan,
Premier Plan,
Premier Plan Plus (H3811_MM662 Approved)
Special Needs Plan (H3811_MM761 Approved)
2011 Evidence of Coverage
Premier Plan,
Premier Plan Plus,
Special Needs Plan (H3811_MM171 Approved)
Conventional Plan (H3811_MM170 Approved)
2011 Formulary (List of Covered Drugs)
Your Samaritan Advantage Health Plan HMO Formulary contains a listing of covered drugs, their co-pays, and any prior authorization requirements or quantity limits. See
INSTRUCTIONS BELOW on how to search the document for a specific medication. This formulary does not contain the names of all medications available in the market. If your medication is not listed, please contact Samaritan Advantage Customer Service for assistance.
Premier Plan,
Premier Plan Plus,
Special Needs Plan (H3811_RX250 Approved)
How to take full advantage of your 2011 drug benefits (H311_RXED100 Approved)
D R U G B E N E F I T S I N F O R M A T I O N U P D A T E S
2011 Formulary Prior Authorization requirements, updated 04/28/2011
2011 Formulary Step Therapy requirements, updated 04/28/2011
2011 Formulary Update, updated 06/29/2011
IMPORTANT NOTICE: A change in the law requires companies that make brand-name prescription drugs to give a discount on those drugs to Medicare. Beginning January 1, 2011, prescription drugs made and sold by companies that have not agreed to give a discount to Medicare can no longer be covered (paid for) by Medicare Prescription Drug Plans.
ADOBE READER SEARCH TIPS for Formulary (List of Drugs) and
Provider/Pharmacy Directory |
| Once you have opened the links to the Formulary or Provider Directory found below, you can search the document for a specific prescription drug, network provider, or network pharmacy. Just hold down the Ctrl + f keys on your keyboard to use the "Find" function within Adobe Reader, then type in the name of the drug, provider, or pharmacy that you are seeking. |
Provider/Pharmacy Directory
Samaritan Advantage Health Plan HMO has an extensive provider network for your needs. See "
Search Tips" above for instructions on how to search this document for a specific provider or facility. Please note that provider information may change at any time. We recommend that you confirm your provider's network status and level of coverage PRIOR TO SEEKING SERVICE.
Provider/Pharmacy Directory, created September, 2010 (H3811_MM441 Approved)
P R I O R A U T H O R I Z A T I O N
Coverage of certain medical services and surgical procedures requires Samaritan Advantage Health Plans' written authorization before the services are performed.
Prior Authorization List (2011)
Last modified: June 1, 2011
H3811_MA4002 CMS Approved 10.22.2010