Getting started with Samaritan Advantage Health Plan HMO

 

Come on in! We've been waiting for you.

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.

Shopping for a 2011 plan?

Your benefits

Below you will find member materials and forms for Samaritan Advantage Health Plan HMO. For more details about your plan, go here ››.

• Summary of Benefits
• Evidence of Coverage
• Formulary (List of covered drugs)
• Provider and Pharmacy Directories		 • Member rights
• Notifications
• Prescription drug forms
• Member forms

Your member materials are important documents that describe your health insurance benefits in detail. You will need Adobe Acrobat Reader in order to view these documents. Get Acrobat Reader here for free ››

2012 Summary of Benefits
Conventional Plan | Premier Plan | Premier Plan Plus (H3811_MM662_2012A CMS Approved)
 Special Needs Plan (H3811_MM761_2012A CMS Approved)

Take advantage of the many free or low cost medical benefits available to you.

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

IMPORTANT NOTICE: NEW Services added to the Preventive Benefit!

CMS has added four new services for 2011 and one new service for 2012 under the Preventive Benefit. These will be covered under Original Medicare with no out-of-pocket cost to our members:

  • Covered starting October 14, 2011: Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse and Screening for Depression in Adults.
  • Covered starting November 8, 2011: Screening for Sexually Transmitted Infections (STIs), High Intensity Behavioral Counseling to Prevent STIs, and Intensive Behavioral Therapy for Cardiovascular Disease.
  • Covered starting January 1, 2012: Health Risk Assessment (HRA) as part of the Annual Wellness Visit

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)

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.
List of Primary Care Providers, updated weekly
List of Specialty Providers, updated weekly
Pharmacy Directory, created September, 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.
 2012 Prior Authorization List

Member Rights
Notifications
Privacy notice

Prescription drug forms

Prescription Exception or Coverage Determination: You can ask us to make a medication exception to our coverage rules if you are a member of one of our plans that offer prescription drug coverage.

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: October 21, 2011
H3811_MA4003_2012 CMS Approved 10/14/2011

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".

You can find the standard Medicare Appointment of Representative form here ››

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 (H3811_AP7001 Approved): 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. 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 copayments/coinsurance may change on January 1, 2013. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. Limitations, copayments and restrictions may apply. Other providers are available in our network. For more information contact Samaritan Advantage Health Plan.
© 2011 Samaritan Health Services