2012 Plan documents 

Here you can download Samaritan Advantage Health Plan HMO documents.

2012 Summary of Benefits
 Conventional Plan, Premier Plan, Premier Plan Plus  (H3811_MM662_2012A CMS approved)
 Special Needs Plan (H3811_MM761_2012A CMS approved)

2012 Evidence of Coverage
 Premier Plan, Premier Plan Plus (H3811_MM171_2012A CMS approved)
 Special Needs Plan (H3811_MM172_2012A CMS approved)
 Conventional Plan (H3811_MM170_2012A CMS approved)

2012 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, Special Needs Plan (H3811_RX251_2012A CMS approved)
 Premier Plan Plus (H3811_RX250_2012A CMS approved)

 Formulary List Changes, updated 07/24/2012

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
 2012 Formulary Prior Authorization requirements, updated 09/09/2011


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 Directory, created August, 2011  (H3811_MM441_2012A CMS approved)
 Pharmacy Directory, created August, 2011 (H3811_RX320_2012B CMS 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 (H3811_PA_2012B CMS approved)

O T H E R  L I N K S
 2012 STAR Ratings (H3811_MA720_2012 CMS approved)

Last modified: October 24, 2012
H3811_MA4001_2012A CMS Approved October 24, 2012