Getting started with Samaritan Choice Plans

Welcome, Samaritan Choice members!

Every day we make choices about our health, and those choices can make a positive difference in our own health and the overall health of our organization. When we are as healthy as we can be, we can strengthen the wellbeing of those who depend on us: Our families, our patients, our communities. By taking steps to achieve and maintain good health, we help to create a better future—one that positively impacts the cost, quality and availability of health care here at home. Check out your Everyday Choices program opportunities!

Your coverage information:
Summary of Material Modifications:
2014 Basic Plan | 2014 High Deductible Plan | 2014 Wellness Plan

Medical and Pharmacy Member Handbook:
2013 Basic Plan | 2013 High Deductible Plan | 2013 Wellness Plan

Vision Member Handbook:
2013 Basic Plan | 2013 High Deductible Plan | 2013 Wellness Plan

Summary of Benefits and Coverage:
2014 Basic Plan | 2014 High Deductible Plan | 2014 Wellness Plan

List of covered drugs and pharmacies:
2013 Formulary
Network Pharmacies

Network providers: 
List of Primary Care Providers 
List of Specialty Providers

Prior authorization:
Coverage of certain medical services and surgical procedures requires Samaritan Choice Plans' written authorization before the services are performed.
2014 Prior Authorization List

Need information about your 2013 plan?

Additional Resources 
COBRA continuation coverage
2014 plan comparison
Privacy Notice 
Glossary of Terms
Information on double coverage

Your member forms

The following forms should be sent to Samaritan Choice Plans:

Medical reimbursement claim:
Request reimbursement for services that you have received and paid for that are a covered benefit.

Prescription reimbursement claim:
Request reimbursement for prescriptions obtained at a non-participating pharmacy.

Coordination of Benefits:
To properly process your claims, Samaritan Choice Plans needs periodic updates regarding your other health insurance coverage. More information on double coverage.

Disabled Dependent Certification:
Request continuance of coverage for a dependent that is reaching the limiting age of coverage.

Medication Exception:
Request medication exception to Samaritan Choice Plans’ coverage rules, e.g., covering your drug even if it is not on the formulary, waiving coverage restrictions or limits on your drug, or providing a higher level of coverage for your drug.

Prescription Mail Order Form:
Use this form when you have a written prescription that you are mailing from a Samaritan Health Services pharmacy.

Authorized Representative Form:
Use this form to confirm permission for Samaritan Choice Plans to discuss or disclose your protected health information to a particular person who acts as your Authorized Representative.

SCP Appeal Request:
Use this form if you intend to appeal a benefit coverage decision made by Samaritan Choice Plans.

Member Request for Health Plan Records Form:
You are required to complete and send this form to the Health Plan at the address indicated  when requesting any documentation from Samaritan Choice Plans.



Last modified: May 14, 2014

Forms for your local Samaritan Human Resources Department

The following forms need to be turned into your local Samaritan Human Resources Department for approval:

Affidavit of Domestic Partnership:
Add a person to the health plan as a Domestic Partner if criteria have been met.

Declination of Coverage:
Samaritan offers an additional amount in each paycheck to employees who decline health plan coverage even though they are eligible. The amount of the additional income is determined by Samaritan each year. To decline coverage, you must complete and submit this form within 30 days of the close of open enrollment each year. You must be able to provide proof of other coverage.


Wellness Plus reimbursement form

Use this form to request annual reimbursement for the Wellness Plus benefit. Follow instructions that indicate where to send this form. DO NOT fax or mail to Samaritan Choice Plans. Go here for details on this benefit.