Coverage redetermination

Coverage redetermination

A coverage redetermination is when you want us to reconsider and change a decision we have made about what services or benefits are covered for you or what we will pay for a service or benefit. For example, if we deny the request for coverage determination and you think we should cover the medication, you can request a redetermination.

There are two kinds of coverage redeterminations you can request:

Expedited requests
You can request an expedited (fast) coverage redetermination for cases that involve coverage, if you or your doctor believes that your health could be seriously harmed by waiting for a standard decision. For expedited requests, you or the prescribing physician may call Customer Service at (541) 768-4550 or 1-800-832-4580, from 8 a.m. to 8 p.m. TTY users should call 1-800-735-2900. If your request to expedite is granted, the reviewer must give you a decision no later than 72 hours after receiving your request.

Standard requests
You can request a standard coverage redetermination for a case that involves coverage or payment for prescription services. You must file a request for coverage redetermination to Samaritan Advantage Health Plan HMO no later than 60 days from the date of the denial. The plan will review your request and make a determination as expeditiously as your health requires, but no later than 7 days from the date of the request.

Please include the following information:

  • Name
  • Address
  • Member ID number
  • The reasons for your request
  • Any evidence you wish to attach.
If your request relates to a decision by us to deny a drug that is not on our list of covered drugs (formulary), your prescribing physician must indicate that all the drugs on any tier of our formulary would not be as effective to treat your condition as the requested off-formulary drug or would harm your health. You or your appointed representative should mail your written request to the address below:

Samaritan Advantage Health Plan
Attn: Part D Pharmacy Dept.
PO Box M
Corvallis, OR 97339

Authorized Representative
As a member of Samaritan Advantage Health Plan HMO, you have appeal rights to adverse organization determinations for services requested. You also have the right to appoint any individual (such as a relative, advocate, friend, attorney or any physician) to act as your representative and file an appeal on your behalf.

By appointing a representative to act on your behalf concerning your appeal, you are giving him or her the right to:

  • Obtain information about your claim to the extent consistent with Federal and State laws;
  • Submit evidence;
  • Make statements of fact and law; and
  • Make any request, or give or receive any notice about the appeal proceedings.

To appoint a representative for your Medicare benefits, both you and the representative you’ve assigned must sign, date and complete an Authorized Representative Form* from Medicare. 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.
* By clicking on this link, you will be directed to an external website.

Extra help for prescription drug costs

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or your State Medicaid office.

In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Quantity limitations and restrictions may apply.

Last modified: October 1, 2012
H3811_MA4001_2012A CMS Approved October 24, 2012