Samaritan Healthy KidsConnect

Welcome, Samaritan Healthy KidsConnect Members!

Samaritan Healthy KidsConnect, through the Oregon Healthy Kids Program, provides families with comprehensive medical, pharmacy, dental, vision and mental health and chemical dependency coverage for their children at affordable rates. This option is available for families residing in Benton, Linn, Lincoln and Tillamook Counties who meet specific eligibility criteria.

A S S I S T A N C E I S A V A I L A B L E
Subsidies are available to help pay premiums for qualifying families between 200 and 300 percent of the federal poverty level (FPL). Families below 200 percent FPL are able to receive free health insurance for their children through the Oregon Health Plan.

For more information about the health coverage options under the Oregon Healthy Kids Program or
T O E N R O L L I N S A M A R I T A N H E A L T H Y K I D S C O N N E C T:

Go online to www.oregonhealthykids.gov or
Call Oregon Healthy Kids at 1-877-314-5678

Your benefits

Your member materials are important documents that describe your health insurance benefits in detail. Your member materials include:
Member handbook - your benefit plan description that includes covered services, exclusions and limitations.
Summary of benefits - this is a summary of your cost sharing for covered services on the 300% and above plan and the subsidized plan.

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 written authorization from Samaritan Health Plans before the services are performed.
2012 Prior Authorization List

Your network providers

Samaritan Healthy KidsConnect has an extensive provider network for your needs. 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. Call Samaritan Health Plans Customer Service, Monday through Friday, 8 a.m. to 5 p.m.:

1-800-832-4580
Corvallis (541) 768-4550

PCP provider directory - a list of contracted PCP's to choose from to receive treatment and services

Specialist provider directory - a list of contracted specialists to choose from to receive treatment and services

Your pharmacies and covered drugs

P H A R M A C I E S
Samaritan Healthy KidsConnect has a national network of contracted pharmacies. Most major chain pharmacies and many independently-owned pharmacies are contracted with us and can fill prescriptions for you. To find out about a specific pharmacy please contact Customer Service for help.

F O R M U L A R Y
Your Samaritan Healthy KidsConnect Formulary contains a listing of covered drugs, prior authorization requirements and any drug quantity limits. This formulary does not contain the names of all medications available in the market. If your medication is not listed, please contact Customer Service for assistance.
2011 Formulary

Notifications

Letter from the CEO, Kelley Kaiser

Notice of Privacy Practices and Member Rights and Responsibilities: This notification informs you of your Health Insurance Portability and Accountability Act (HIPAA) rights, Appeal Rights and your rights and responsibilities as a member of Samaritan Healthy KidsConnect.

Your member forms

Primary Care Provider (PCP) Change Card: Choose or change a PCP.

Prior Authorization-Referral Form: Request an authorization for Medical services.

Appeals Request Form: Request a medical appeal with SHK.

Medication Exception & Authorization Form: Request medically necessary medications that are not normally covered on SHK’s formulary and for medications that require prior authorization.

Member Reimbursement Form: Request reimbursement for covered services that you have received and paid for out of your pocket.

Prescription Reimbursement Form: Request reimbursement for covered medications that you have received and paid for out of your pocket.

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

Request for Health Plan Records Form: This form is required to be completed when you are requesting any Health Plan documentation from us.

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