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 2016 medical coverage information:
2016 Summary of Benefits:
Summary of Benefits - Conventional Plan, Premier Plan and Premier Plan Plus (PDF)
Summary of Benefits - Special Needs Plan (PDF)
Over-the-Counter (OTC) Benefits - Special Needs Plan (PDF)

2016 Evidence of Coverage:
Evidence of Coverage - Conventional Plan (PDF)
Evidence of Coverage - Premier Plan and Premier Plan Plus (PDF)
Evidence of Coverage - Special Needs Plan (PDF)

2016 Annual Notice of Change:
Annual Notice of Change - Conventional Plan (PDF)
Annual Notice of Change - Premier Plan (PDF)
Annual Notice of Change - Premier Plan Plus (PDF)
Annual Notice of Change - Special Needs Plan (PDF)

Your 2016 Medicare Part D prescription drug information:
The formularies may change throughout the year. See "Search Tips For PDF Documents" below on how to search the formularies for a specific medication. These formularies do 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. You can contact the plan for the most recent list of drugs at 1-800-832-4580 (TTY 1-800-735-2900), 8 a.m. to 8 p.m. daily.

Please note that formularies are updated and may change throughout the year. The most recent formulary documents are found below.

2016 Formularies (list of covered drugs):
Premier Plan Formulary (PDF)
Premier Plan Plus Formulary (PDF)
Special Needs Plan Formulary (PDF)

Premier and Premier Plan Plus Formulary documents:
Formulary Prior Authorization Requirements (PDF)
Formulary Quantity Limits (PDF)
Formulary Step Therapy Criteria (PDF)

Special Needs Plan Formulary documents:

Formulary Prior Authorization Requirements (PDF)
Formulary Quantity Limits (PDF)
Formulary Step Therapy Criteria (PDF)

If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact Samaritan Advantage Customer Service to obtain more information on how to request an exception or switch to an alternative drug listed on our formulary with your physician's help.


After you have opened the PDF document, 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, pharmacy, facility or provider that you are seeking.

Your 2016 network pharmacies:
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.
Pharmacy Directory (PDF)

Your network providers: 
List of Providers (PDF), updated weekly

Prior authorization:

Coverage of certain medical services and surgical procedures requires Samaritan Advantage Health Plans' written authorization before the services are performed.
2016 Prior Authorization List (PDF)

Do you qualify for extra help?
2016 Low Income Subsidy information

What are your rights as a member?
Member rights information 

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:
  • Samaritan Health Plans Authorized Representative Form (PDF)
    - OR -
  • To designate a representative for appeals ONLY: (By clicking this link, you will leave the Samaritan Advantage website) CMS Form-1696, Appointment of Representative (PDF).

    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)

Prevent Medicare Fraud:
Protecting Medicare Future Generations (PDF)
Identity Theft Protection (PDF)
Detecting Home Health Fraud (PDF)
Reporting Medical Transport Fraud (PDF)
Reporting Health Insurance Marketplace Fraud (PDF)
Questioning Free Medical Supplies (PDF)
Reporting Services Not Provided (PDF)

Save time — go online!

Your member portal at provides you with secure, 24/7 access to:
  • Claims processed by your health plan
  • Details about your eligibility with the health plan, including the amount you have met toward your deductibles, your plan limits, and summary of benefits
  • A new treatment cost estimator for select services
  • The National Library of Medicine’s MedlinePlus Connect for consumer-friendly health information in both English and Spanish

For questions about your member portal and technical support if needed, please contact Customer Service.

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 (PDF):
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: Feb. 1, 2016 
CMS approved 10/15/2015

Your member forms

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

Request reimbursement for medical or dental services (PDF): 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. 

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

Request for Health Plan Records (PDF): 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.

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