What are the benefits for 2014?

Compare our plans

With Samaritan Advantage plans, you have lots of options available to you for 2014. All of our plans provide coverage for routine and specialty care you need, with full access to our extensive provider network. We also have plan options that offer the Medicare Part D prescription coverage you may need. Here is a brief summary of the differences between each plan:

  Conventional Plan
$72/month
Premier Plan
$105/month
Premier Plan Plus
$135/month
Medical and hospital Yes Yes Yes
Prescription drugs (Part D)   Yes Yes
Other benefits:
  • Dental visits
  • Gap RX coverage
  • Hearing aids
  • Out-of-pocket max for DME
    Yes

For detailed information on each plan, click on the links below:

Conventional Plan

CONVENTIONAL PLAN HMO
$72 / month
2014 BENEFIT HIGHLIGHTS
Deductible $0 annual deductible
Medical out-of-pocket maximum $3,400 (The most you will pay per year for medical co-pays and coinsurance)
Hospitalization Out-of-pocket maximum: $1,750/year
$175/day for days 1-5
$0/day for days 6-90
Doctor office visits Primary care visit: $10 co-pay
Specialist visit: $20 co-pay
Emergency care Worldwide coverage: $50 co-pay
$0 co-pay if you are admitted to the hospital within 12 hours
$100 co-pay for ambulance
Urgent Care Anywhere in the U.S.: $25 co-pay
Routine physical exams $0 co-pay
Skilled nursing facility care Days 1-120 in a facility: $40 co-pay
Chiropractic / acupuncture $20 co-pay for manual manipulation of the spine to correct subluxation
$25 co-pay for up to 5 routine chiropractic visits per year
$20 co-pay per acupuncture visit; up to 15 visits per year
Vision services
(Eye wear does not apply to annual medical out-of-pocket maximum)
Exam to diagnose and treat eye conditions and diseases: $20 co-pay
Routine eye exam: $30 co-pay for each; limited to 1 exam every 2 years
Eye wear: up to $125 for every 2 years
Preventive and diagnostic services $0 co-pay for most services (Refer to the Summary of Benefits for details.)
Outpatient prescription drugs (Part D) No.
Only available with the Premier and Premier Plan Plus HMO Plans.
Dental services
(Does not apply to annual medical out-of-pocket maximum)
No.
Only available with the Premier Plan Plus HMO.
Hearing aids and equipment
(Does not apply to annual medical out-of-pocket maximum)
No.
Only available with the Premier Plan Plus HMO.
Out-of-pocket maximum for durable medical equipment No.
Only available with the Premier Plan Plus HMO.

2014 Summary of Benefits

Conventional Plan (PDF)

2014 Evidence of Coverage

Conventional Plan (PDF)

Premier Plan

PREMIER PLAN HMO
$105 / month
2014 BENEFIT HIGHLIGHTS
Deductible $0 annual deductible
Medical out-of-pocket maximum $3,400 (The most you will pay per year for medical co-pays and coinsurance)
Hospitalization Out-of-pocket limit: $1,750/year
$185/day for days 1-5
$0/day for days 6-90
Doctor office visits Primary care visit: $10 co-pay
Specialist visit: $20 co-pay
Emergency care Worldwide coverage: $65 co-pay
$0 co-pay if you are admitted to the hospital within 12 hours
$150 co-pay for ambulance
Urgent care Anywhere in the U.S.: $25 co-pay
Routine physical exams $0 co-pay
Skilled nursing facility care Days 1-120 in a facility: $40 co-pay
Chiropractic / acupuncture $20 co-pay for manual manipulation of the spine to correct subluxation
$25 co-pay for up to 5 routine chiropractic visits per year
$20 co-pay per acupuncture visit; up to 15 visits per year
Vision services
(Eye wear does not apply to annual medical out-of-pocket maximum)
Exam to diagnose and treat eye conditions and diseases: $20 co-pay
Routine eye exam: $30 co-pay for each; limited to 1 exam every 2 years
Eye wear: up to $125 for every 2 years
Preventive and diagnostic services $0 co-pay for most services (Refer to the plan's Summary of Benefits for details.)
Outpatient Prescription Drugs **
(see Are my drugs covered?)
$0 annual deductible
$0 co-pay for: Enalapril, Lisinopril (high blood pressure), Lovastatin, Simvastatin (high cholesterol), Glipizide, Glyburide, Metformin (diabetes)
Maximum $9 co-pay for generic formulary drugs
Maximum $40 co-pay for preferred brand drugs
Maximum $80 co-pay for non-preferred drugs
30% coinsurance for specialty drugs
Once your total drug spend reaches $2,850, you receive Medicare's discount on generic and brand name drugs.
After you have spent $4,550 out-of-pocket, you will pay the greater of $2.55 and $6.35 co-pays or 5% coinsurance.
Dental Benefit
(Does not apply to annual medical out-of-pocket maximum)
No.
Only available with the Premier Plan Plus HMO.
Hearing Aids Benefit
(Does not apply to annual medical out-of-pocket maximum)
No.
Only available with the Premier Plan Plus HMO.
Out-of-pocket maximum for durable medical equipment No.
Only available with the Premier Plan Plus HMO.

2014 Summary of Benefits

Premier Plan (PDF) 

2014 Evidence of Coverage

Premier Plan (PDF) 

See 2014 Prescription Drug Benefits

Samaritan Advantage Health Plan HMO has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area.

**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 Administration 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.

Premier Plan Plus

PREMIER PLAN PLUS HMO
$135 / month
2014 BENEFIT HIGHLIGHTS
Deductible $0 annual deductible
Medical out-of-pocket maximum $3,400 (The most you will pay per year for medical co-pays and coinsurance)
Hospitalization Out-of-pocket limit: $1,750/year
$185/day for days 1-5
$0/day for days 6-90
Doctor office visits Primary care visit: $10 co-pay
Specialist visit: $20 co-pay
Emergency care Worldwide coverage: $65 co-pay
$0 co-pay if you are admitted to the hospital within 12 hours
$150 co-pay for ambulance
Urgent care Anywhere in the U.S.: $25 co-pay
Routine physical exams $0 co-pay
Skilled nursing facility care Days 1-120 in a facility: $40 co-pay
Chiropractic / acupuncture $20 co-pay for manual manipulation of the spine to correct subluxation
$25 co-pay for up to 5 routine chiropractic visits per year
$20 co-pay per acupuncture visit; up to 15 visits per year
Vision services
(Eye wear does not apply to annual medical out-of-pocket maximum)
Diagnose and treat eye conditions and diseases: $20 co-pay
Routine eye exam: $30 co-pay for each; limited to 1 exam every 2 years
Eye wear: up to $125 for every 2 years
Preventive and diagnostic services $0 co-pay for most services (Refer to the plan's Summary of Benefits for details.)
Outpatient prescription drugs **
(see Are my drugs covered?)
 $0 annual deductible
$0 co-pay for: Enalapril, Lisinopril (high blood pressure), Lovastatin, Simvastatin (high cholesterol), Glipizide, Glyburide, Metformin (diabetes)
Maximum $9 co-pay for generic formulary drugs
Maximum $40 co-pay for preferred brand drugs
Maximum $80 co-pay for non-preferred drugs
30% coinsurance for specialty drugs
Once your total drug spend reaches $2,850, you will pay whichever is less for generics: Maximum $9 co-pay for generics or Medicare's discounted
cost for generics (whichever is less)and receive Medicare's discount for brand drugs.
After you've spent $4,550 out-of-pocket: you will pay the greater of $2.55 and $6.35 co-pays or 5% coinsurance
Dental Benefit
(Does not apply to annual medical out-of-pocket maximum)
$15 co-pay for each preventive exam (up to 2 routine oral exams with regular cleanings every year; benefit must be utilized 6 months apart)
$0 co-pay for 1 set of dental x-rays per year
Hearing Aids Benefit
(Does not apply to annual medical out-of-pocket maximum)
Up to $500/year
Out-of-pocket maximum for durable medical equipment $2,000 (The most you will pay per year for durable medical equipment coinsurance)

2014 Summary of Benefits

Premier Plan Plus (PDF) 

2014 Evidence of Coverage

Premier Plan Plus (PDF)

For formulary and pharmacy information, see the 2014 Prescription Drug Benefits.

Samaritan Advantage Health Plan HMO has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area.

**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 Administration 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.

Special Needs Plan

This plan is designed for people who meet specific enrollment criteria. This plan is available to anyone who has both Medical Assistance from the State and Medicare. Samaritan Advantage Special Needs Plan has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until 2016 based on a review of Samaritan Advantage Special Needs Plan HMO Model of Care.

Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details at 541-768-4550, 1-800-832-4580 (TTY 1-800-735-2900) from 8 a.m. to 8 p.m., daily.

Below you will find coverage information for Samaritan Advantage Special Needs Plan HMO. These materials are important documents that describe your health insurance benefits in detail.

2014 Summary of Benefits

Special Needs Plan (PDF) 

2014 Over-the-Counter (OTC) Benefits

Special Needs Plan (PDF)

2014 Evidence of Coverage

Special Needs Plan (PDF) 

For formulary and pharmacy information, see the 2014 Prescription Drug Benefits.

Are my drugs covered?

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

Medicare Part D prescription drugs

Find answers to various questions about prescription drug coverage options through Samaritan Advantage.

Are my drugs covered?

Samaritan Advantage Premier, Premier Plus, and Special Needs Plan HMOs use a comprehensive formulary. A comprehensive formulary is a complete list of drugs covered by your plan to meet patient needs.

Samaritan Advantage Premier Plan, Premier Plan Plus, and Special Needs Plan cover specialty drugs, brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

2014 Formularies (list of covered drugs)

The formularies may change throughout the year. See "Adobe Reader Search Tips" 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.

Premier Plan Formulary (PDF)
Premier Plan Plus Formulary (PDF)
Special Needs Plan Formulary (PDF)

Premier and Premier Plan Plus Formulary documents

2014 Formulary Changes (PDF)
Formulary Prior Authorization Requirements (PDF)
Formulary Quantity Limits (PDF)
Formulary Step Therapy Criteria (PDF)

Special Needs Plan Formulary documents

2014 Formulary Changes (PDF)
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.

ADOBE READER SEARCH TIPS for your 2014 Formulary (List of Drugs)

Once you have opened the link to the Formulary found above, you can search the document for a specific prescription drug. 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 that you are seeking.

Network pharmacies

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

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.

For additional help, visit the Medicare Prescription Drug Plan Finder at www.medicare.gov.

Extra Help with 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.

How much will I pay for my drugs?

More benefits, better value

Samaritan Advantage’s Premier and Premier Plus HMO Plans combine a prescription drug plan with a medical benefits package that covers more than original Medicare with less out-of-pocket expenses for you.

2014 Medicare Part D Prescription Drug Benefit

  Premier Plan HMO Premier Plan Plus HMO
Premium $105 $135
Part D Prescription Drugs*

See list of covered drugs
  • Enalapril,Lisinopril (high blood pressure)
  • Lovastatin, Simvastatin (high cholesterol)
  • Glipizide, Glyburide, Metformin (diabetes)
Maximum $9 co-pay generic
Maximum $40 co-pay preferred brand
Maximum $80 co-pay non-preferred
30% coinsurance for specialty drugs
Gap Coverage NO ADDITIONAL COVERAGE

You receive Medicare's discount for generics and brand drugs once your total drug spend reaches $2,850.

After you have spent $4,550 out-of-pocket, you will pay the greater of: $2.55 and $6.35 co-pays or 5% coinsurance
EXTRA COVERAGE FOR GENERICS

You pay a maximum $9 co-pay for generics or Medicare's discounted cost for generics (whichever is less) and receive Medicare's discount for brand drugs once your total drug spend reaches $2,850.

After you have spent $4,550 out-of-pocket, you will pay the greater of: $2.55 and $6.35 co-pays or 5% coinsurance

For full details on medical coverage, see each plan's Evidence of Coverage.

Where can I fill my prescriptions?

Network pharmacy

A network pharmacy is one that we have made arrangements for them to provide prescription drugs to plan members. These pharmacies are where members can obtain prescription drug benefits provided by Samaritan Advantage Premier, Premier Plus, and Special Needs HMO Plans. Samaritan Health Plans has an arrangement with pharmacies all across the United States, which consists of approximately 90 percent of pharmacies. This equals or exceeds CMS requirements for pharmacy access in your area. In most cases, your prescriptions are covered if they are filled at a network pharmacy. Quantity limitations and restrictions may apply.

Pharmacy Directory (PDF)

ADOBE READER SEARCH TIPS for your Pharmacy Directory

Once you have opened the link to the Pharmacy Directory found above, you can search the document for a specific 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 facility or provider that you are seeking.

We also list pharmacies that are in our network but are outside our geographic area. Please contact Samaritan Advantage at 541-768-4550, 1-800-832-4580, TTY users must use 1-800-735-2900, 8 a.m. to 8 p.m. daily, for additional information.

Once you go to a network pharmacy, you are not required to continue going to the same pharmacy to fill your prescription, you can go to any of our network pharmacies.

Out-of-network coverage

In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:

  • If you are unable to obtain a covered drug in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24 hour service
  • If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail pharmacy (including high cost and unique drugs)
  • If you are getting a vaccine that is medically necessary but not covered by Medicare Part B and some covered drugs that are administered in your doctor’s office

Before you fill your prescription in any of these situations, call Customer Service at (541) 768-4550 or 1-800-832-4580 (TTY 1-800-735-2900), 8 a.m. to 8 p.m. daily, to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed above, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. A Prescription Claim Form can be found on our member page.

If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription.

Getting prescriptions filled when you travel

In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Quantity limitations and restrictions may apply. If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. When possible, take along all the medication you will need.

If you are traveling within the United States and territories and become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of network pharmacy. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a Prescription Reimbursement Form. Visit our member page to download and print the form.

If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription.

You can also call Customer Service, to find out if there is a network pharmacy in the area where you are traveling. If there are no network pharmacies in that area, Customer Service may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy. We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.

Mail order drugs

For certain kinds of drugs, members can get prescription drugs shipped to their homes through the network mail-order delivery program. The drugs available through our plan's mail-order service are marked as "mail order" drugs in our formulary. Our plan's mail-order service requires you to order a 90-day supply.

Local provider

You can order your prescriptions for rapid mail delivery from Samaritan Health Services.

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.

Envision Rx Options mail order service

Please call Customer Service to sign up for Envision Rx Options mail order service. Usually a mail-order pharmacy order will get to you in no more than seven days after the pharmacy receives your order. Contact Customer service at 1-800-832-4580 if your mail order is delayed and we will make alternative arrangements for you to get your order.

Complimentary Part D services

Rely on your LOCAL Advantage, Samaritan Advantage Health Plan HMO. If you are a Medicare-eligible individual living in Oregon's Benton, Lincoln or Linn counties, we invite you to take advantage of our complimentary services to aid in your decision making.

Medication review with our Clinical Pharmacist

Sit down with our pharmacist for a personal and confidential review that will help you determine the best approach for managing your prescription medications. As an added benefit, you will receive a Personal Medication Record developed by the pharmacist to ensure that you receive quality medication services from your health providers, and to help you self-manage your drug regimen. Contact our Customer Services at 541-768-4550 or toll free at 1-800-832-4580 (TTY 1-800-735-2900), 8 a.m. to 8 p.m., daily, to schedule your review.

Local consultations

Have a convenient meeting in your neighborhood with one of our knowledgeable representatives. Call 1-866-SHPlans (1-866-747-5267), Monday through Friday from 8:30 a.m. to 5 p.m., to schedule your local consultation today or provide assistance over the phone!

Medication Therapy Management

If you are a member who takes many prescription drugs, or who has high drug costs or chronic diseases, you could be eligible for the Samaritan Advantage Health Plan HMO medication therapy management (MTM) program. Our program is designed by a team of pharmacists and physicians to ensure that you are receiving the appropriate drugs to treat your medical condition. This is a free service for eligible members.

Program Description

Our MTM Program is designed to ensure that covered Part D drugs prescribed to targeted beneficiaries are appropriately used to optimize therapeutic outcomes through improved medication use. We also want to reduce the risk of adverse events, including adverse drug interactions for targeted beneficiaries. The program is furnished by our Clinical Pharmacist, Kristel Jordan, RPH, BCPP, distinguished between ambulatory and institutional settings and is developed in cooperation with licensed and practicing pharmacists and physicians

To qualify for MTM, members must meet the following criteria:

  1. Must be taking a minimum of four drugs covered by Medicare Part D
  2. Must have a prescription drug spend that is greater than or equal to $3,017 per calendar year
  3. Must have a minimum of three chronic diseases that Samaritan Advantage has chosen to monitor, as permitted by CMS:
    • Alzheimer’s Disease
    • Bone Disease - Arthritis - Osteoarthritis
    • Bone Disease - Arthritis - Osteoporosis
    • Chronic Heart Failure (CHF)
    • Diabetes
    • Dyslipidemia
    • End-Stage Renal Disease (ESRD)
    • Hypertension
    • Respiratory Disease - Asthma
    • Acid/Reflux/Ulcers
    • Chronic Non-cancer Pain
    • Multiple Sclerosis

Each eligible MTM member’s drug information is analyzed for potential drug-drug interactions, possible adverse effects of medications, or gaps in care. Every quarter, we automatically enroll qualified members in Envision’s MTM program so they may begin receiving this extra support. Eligible MTM members will receive a letter notifying them that they have been auto-enrolled into the MTM Program.

As an MTM member, you are also eligible to receive a comprehensive medication review. We will offer participation by mail and in some cases by phone. The comprehensive medication review will give you the opportunity to review all of your current medications with a pharmacist. This is a one-on-one conversation by phone that takes about 30 minutes. After completing the review, you will be mailed a personal medication list and a medication action plan. The list will include your current prescription medications, over-the-counter medications and dietary and herbal supplements. You can obtain a blank list here. The medication action plan will summarize what you and the pharmacist discussed during the medication review and discussion topics for you and your doctor. We will also conduct ongoing Targeted Medication Reviews and your doctor may be contacted by mail if we identify and issues with your medications.

Members who meet the MTM criteria are requested to participate in the program. Members are allowed to decline this service at any time during the contract year. During the contract year members may enroll into the MTM if they still meet the criteria.

The MTM is not a benefit, but a service provided by Samaritan Advantage. Members are encouraged to contact the plan's Customer Service department for more information.

Coverage requirements and limits

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members. Examples of utilization management tools are described below:

Coverage determinations

We require you to get prior authorization for certain drugs. This means that you, your authorized representative or your provider will need to get approval from us before you fill your prescription. If they don’t get approval, we may not cover the drug.

Quantity Limits

For certain drugs we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to 12 doses per prescription for Zomig.

Step Therapy

In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

Generic Substitution

When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug.

You can find out if your drug is subject to these additional requirements or limits by looking in the formulary. If your drug does have these additional restrictions or limits, you can ask us to make an exception to our coverage rules. For further information regarding how to ask for an exception please refer to the Evidence of Coverage found with enrollment materials.

Other important information regarding prescription drug coverage:

See the list of covered drugs and our member page to request a medication exception/coverage determination.

Plan transition process

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 Customer Service to request an exception or switch to an alternative drug listed on our formulary, with your physician’s help. Contact us to see if you can get a temporary supply of the drug or for more details about our drug transition policy.

Customer Service

541-768-4550 or 1-800-832-4580, from 8 a.m. to 8 p.m. daily
TTY users should call 1-800-735-2900

Medication exception/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: the Samaritan Advantage Premier, Premier Plus, and Special Needs Plans (HMO). This includes exceptions for:

  • Covering your drug even if it is not on our formulary.
  • Waiving coverage restrictions or limits on your drug.
  • Providing a higher level of coverage for your drug. (Premier and Premier Plus only)

To request an exception, you, your authorized representative, or the prescribing physician have the following options:

  • Call Customer Service at 1-800-832-4580 (toll free) or TTY 1-800-735-2900, daily from 8 a.m. to 8 p.m.
  • Complete our authorized representative form (PDF) and mail, fax or drop by our office.
  • Complete our Electronic Formulary Exception Request online.
  • Complete a Drug Coverage Determination Request Form (PDF) and mailing or faxing the completed form to:
    Mail:
    Samaritan Advantage Health Plan HMO
    P.O. Box 1310
    Corvallis, OR 97339
    Fax:
    877-502-9254
  • Deliver the completed form in person to our office in Corvallis at 815 NW Ninth Street, Mon.–Fri., 8:30 a.m. to 5 p.m.
Mail:
Samaritan Advantage Health Plan HMO
P.O. Box M
Corvallis, OR 97339
Fax:
1-877-502-9254
You can find the coverage determination form and redetermination request form under member rights.

Expedited Requests

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. daily. TTY users should call 1-800-735-2900.

Please note: If we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

In order to help us make a decision more quickly, you should include supporting medical information from your doctor when you submit your medication exception request. If we approve your medication exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. If we deny your medication exception request, you can appeal our decision. For drugs with a Part B versus D administrative prior authorization requirement: This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

Drug coverage redetermination

A drug coverage redetermination is when you want us to reconsider and change a decision we have made about what drugs are covered for you or what we will pay for a drug. 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 HMO
Attn: Part D Pharmacy Dept.
PO Box M
Corvallis, OR 97339
Drug Redetermination Request Form (PDF)

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 Medicare's authorized request form. 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.

Extra Help for prescription drug costs

Low Income Subsidy

If you qualify for the Low Income Subsidy (also called "Extra Help") with your Medicare prescription drug plan costs, your premium and costs at the pharmacy will be lower. When you join one of our plans, Medicare will tell us how much Extra Help you are getting. Then we will let you know the amount you will pay.

How to inquire about Low Income Subsidy

If you are not getting Extra Help, you can see if you qualify by calling Social Security at 1-800-772-1213 (TTY users should call 1-800-325-0778) or visit www.socialsecurity.gov.

2014 monthly premiums

The following chart outlines the premium amounts based on the various low income subsidy levels.
Conventional Plan $72/month Premier Plan $105/month Premier Plan Plus $135/month
25% Low Income Subsidy (LIS)

N/A

You pay $96.30* You pay $126.30*
50% Low Income Subsidy (LIS)

N/A

You pay $87.60* You pay $117.60*
75% Low Income Subsidy (LIS)

N/A

You pay $78.90* You pay $108.90*
100% Low Income Subsidy (LIS)

N/A

You pay $70.20* You pay $100.20*
* The premiums listed above include both medical service and prescription drug benefits. These premiums do not include any Medicare Part B premium you may have to pay.

See also the Centers for Medicare and Medicaid Services (CMS) Best Available Evidence Policy.

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

 

Member rights

Members of Samaritan Advantage Health Plan HMO have the right to make a complaint for concerns or problems related to their coverage or care or to ask us to cover a specific medical service. These rights include:

A grievance

A “grievance” is the type of complaint you make if you have any type of problem with Samaritan Advantage Health Plan HMO or one of our plan providers. You would file a grievance if you have a problem with, for example, the quality of your care, waiting times for appointments or time spent in the waiting room, the way your doctors, pharmacists or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor’s office or pharmacy. A grievance needs to be filed within 60 days of the event.

If you have a grievance, we encourage you to first call Customer Service at 541-768-4550 or toll-free at 1-800-832-4580 (TTY 1-800-735-2900), 8 a.m. to 8 p.m. daily.

You may also mail your grievance to:
Samaritan Advantage Health Plan HMO
P.O. Box M
Corvallis, OR 97339

We will try to resolve any grievance that you might have over the phone. If you request a written response to your phone grievance, we will respond in writing to you. If we cannot resolve your grievance over the phone, we have a formal procedure to review your grievance. Depending on the nature of the complaint, your grievance is forwarded to an Operations Manager who is responsible for investigating and resolving the matter. We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your grievance. We may extend the time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

You can also find more information on how to file a grievance or an expedited grievance with our plan in your 2013 Evidence of Coverage. If you are a Conventional plan member, you will find step-by-step instructions on how to file a grievance in Chapter 7. Special Needs Plan, Premier Plan and Premier Plan Plus members will find this information in Chapter 9 of your Evidence of Coverage.

For quality of care problems, you may also file a grievance to Livanta. Livanta is the quality improvement organization that oversees our plan decisions. If you are concerned about the quality of care you received, including care during a hospital stay, you can file a grievance directly to Livanta:

Livanta
BFCC-QIO Program
9090 Junction Drive, Suite 10
Annapolis Junction, MD 20701
Toll Free: 1-877-588-1123
TTY: 1-855-887-6668
Fax: 1-844-420-6672

A coverage determination and medication exception

You can ask us to make a medication coverage determination or exception to our coverage rules if you are a member of one of our plans that offer prescription drug coverage: the Samaritan Advantage Premier Plan HMO; Samaritan Premier Plan Plus HMO; or the Samaritan Advantage Special Needs Plan HMO SNP. This includes exceptions for:

  • Covering your drug even if it is not on our formulary.
  • Waiving coverage restrictions or limits on your drug.
  • Providing a higher level of coverage for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for this drug.

Generally, we will only approve your request for an exception if the alternative drugs included on the plan's formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects. In order to help us make a decision more quickly, you should include supporting medical information from your doctor when you submit your medication exception request. If we approve your medication exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. If we deny your medication exception request, you can appeal our decision.

A coverage determination may be requested by you, your appointed representative*, your provider, or other prescriber in the following ways:

  • Call Customer Service at 1-800-832-4580 (toll free) or TTY 1-800-735-2900, daily from 8 a.m. to 8 p.m.
  • Complete our authorized representative form (PDF) and mail, fax or drop by our office.
  • Complete our Electronic Formulary Exception Request online.
  • Complete a Drug Coverage Determination Request Form (PDF) and mailing or faxing the completed form to:
    Mail:
    Samaritan Advantage Health Plan HMO
    P.O. Box 1310
    Corvallis, OR 97339
    Fax:
    877-502-9254
  • Deliver the completed form in person to our office in Corvallis at 815 NW Ninth Street, Mon.–Fri., 8:30 a.m. to 5 p.m.

*Find out how to appoint an authorized representative on our member page.

An organization determination

An Organization Determination is a coverage decision we make about your medical benefits and coverage or about the amount we will pay for your medical services. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal. You can also find more information on how to ask for a coverage decision in your 2013 Evidence of Coverage. If you are a Conventional plan member, you will find instructions on how to ask for a coverage decision in Chapter 7. Special Needs Plan, Premier Plan and Premier Plan Plus members will find this information in Chapter 9 of your Evidence of Coverage.

An organization determination may be requested by you, your appointed representative*, or your provider in the following ways:

  • By calling Customer Service at 1-800-832-4580 (toll free) or TTY 1-800-735-2900, daily from 8 a.m. to 8 p.m.
  • By completing a Prior Authorization Request Form (PDF) and mailing or faxing the completed form to:
    Mail:
    Samaritan Advantage Health Plan HMO
    P.O. Box M
    Corvallis, OR 97339
    Fax:
    541-768-9766

*Find out how to appoint an authorized representative on our member page.

An appeal

An "appeal" is the type of complaint you make 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 refuse to cover or pay for services you think we should cover, you can file an appeal. If Samaritan Advantage Health Plan HMO or one of our plan providers refuses to give you a service you think should be covered, you can file an appeal. If Samaritan Advantage or one of our plan providers reduce or cuts back on services or benefits you have been receiving, you can file an appeal. If you think we are stopping your coverage of a service or benefit too soon, you can file an appeal. If you think that we should have covered a prescription that was denied through the medication exception process, you can file an appeal.

Important information about your appeal rights

For more information about your appeal rights, call us or see your Evidence of Coverage. If you are a Conventional plan member, you will find step-by-step instructions on how to file an appeal in Chapter 7. Special Needs Plan, Premier Plan and Premier Plan Plus members will find this information in Chapter 9 of your Evidence of Coverage.

There are two kinds of appeals you can request:

  1. Expedited Requests—You can request an expedited (fast) appeal for cases that involve coverage, if you or your doctor believes that your health could be seriously harmed by waiting for a standard decision. If your request to expedite is granted, the reviewer must give you a decision no later than 72 hours after receiving your appeal.
  2. Standard Requests—You can request a standard appeal for a case that involves coverage or payment for medical or prescription services. The reviewer must give you a decision within a specific timeframe as described below, depending on whether the request is for medical or prescription services.

You can request an expedited (fast) appeal for cases that involve coverage, if you or your doctor believes that your health could be seriously harmed by waiting for a standard decision. If your request to expedite is granted, the reviewer must give you a decision no later than 72 hours after receiving your appeal. You can request an expedited (fast) appeal for cases that involve coverage, if you or your doctor believes that your health could be seriously harmed by waiting for a standard decision. If your request to expedite is granted, the reviewer must give you a decision no later than 72 hours after receiving your appeal. You can request a standard appeal for a case that involves coverage or payment for medical or prescription services. The reviewer must give you a decision within a specific timeframes as described below, depending on whether the request is for medical or prescription services.

Timeframes for a request regarding your MEDICAL BENEFITS

You must file your request for appeal to Samaritan Advantage no later than 60 days after receiving the denial for your services or denial of payment. Samaritan Advantage will review your appeal request and make a determination as expeditiously as your health requires, but no later than 30 days from the date the appeal request was received. For payment it is 60 days from the date the appeal request is received.

Timeframes for a request regarding your PRESCRIPTION BENEFITS

You must file a request for appeal to Samaritan Advantage no later than 60 days from the date of the denial. Samaritan Advantage will review your appeal request and make a determination as expeditiously as your health requires, but no later than 7 days from the date of the request.

What do I include with my appeal?

You should include your name, address, Member ID number, the reasons for appealing, and any evidence you wish to attach. If your appeal relates to a decision by us to deny a drug that is not on our list of covered drugs (formulary), you 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.

How do I request an appeal?

An appeal request form can be used to request an appeal of a medical care or prescription coverage decision made by our plan. You or your appointed representative* can mail or fax your written appeal request form (PDF) to Samaritan Advantage:

Mail:
Samaritan Advantage Health Plan HMO
P.O. Box M
Corvallis, OR 97339
Fax:
541-768-9765 (Medical Appeals)
or
1-877-502-9254 (Pharmacy Appeals)

If your appeal request is for a prescription drug, please address to "Part D Appeals" and send to the address above.

What happens next?

After reviewing your appeal, we will decide whether to stay with our original decision, or change this decision and give you some or all of the care or payment you want. If we turn down part or all of your request for medical service, we are required to send your request to an independent review organization that has a contract with the federal government and is not part of Samaritan Health Plans. This organization will review your request and make a decision about whether we must give you the care or payment you want. If we turn down part or all of your request for a prescription, you may request an independent review organization to review your appeal.

If you are unhappy with the decision made by the independent review organization, you may ask for an Administrative Law Judge (ALJ) to consider your case and make a decision. The ALJ works for the federal government. For 2012, the dollar value of your contested benefit must be at least $130** to be considered by the ALJ.

If you or we are unhappy with the decision made by the Medicare Appeals Council, either of us may be able to take your case to a Federal Court. In 2012, the dollar value of your contested medical care must be at least $1,350** to go to a Federal Court.

*Find out how to appoint an authorized representative on our member page.
**These amounts may change in 2013.

Filing your complaint directly with Medicare

Members are now able to submit feedback about their Medicare health plan or prescription drug plan directly to Medicare. Medicare values the satisfaction of its members and will use this information to continue to improve the quality of its program. If you have any other feedback or concerns, or if this is an urgent matter, please call 1-800-MEDICARE (1-800-633-4227). TTY/TTD users can call 1-877-486-2048. Members can access the Medicare Complaint Form.

For help with complaints, grievances, and information requests, contact The Office of the Medicare Ombudsman.

To obtain an aggregate number of appeals, grievances and exceptions for Samaritan Advantage Health Plan HMO, go to the Medicare website. Here are brief instructions on how to use the Medicare website:

  • Select “Learn More About Plans In Your Area”
  • Then select your “State” and “Continue”
  • Then select your county in “Select a county” and “Continue”
  • From the page “Plans in Your Area” under “Review List of Plans”, select “Get Plan Performance Information” and find Samaritan Advantage’s plans

If you, your authorized representative*, or your provider have a question regarding the status of your appeal, grievance, medication exception or coverage determination, please contact our Customer Service department at 541-768-4550, 1-800-832-4580 (TTY 1-800-735-2900), 8 a.m. to 8 p.m. daily.

*Find out how to appoint an authorized representative on our member page.

See our frequently asked questions regarding enrollment and disenrollment for more information.

Connect me to an expert for FREE Medicare advice.
Send me a free decision kit.
Schedule a one-on-one appointment.

Samaritan's Medicare Advantage plans are available in Benton, Lincoln and Linn counties, Oregon.
Visit us Monday - Friday, 8:30 a.m. to 5 p.m. at 815 NW Ninth Street, Corvallis, Oregon. Click here for a map.

Samaritan Advantage Health Plan HMO is a coordinated care plan with a Medicare Advantage Contract and a contract with the Oregon Medicaid program. Enrollment in Samaritan Advantage Health Plan HMO depends upon contract renewal. Individuals must have both Medicare 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 B premiums. The Part B premium is covered for full-dual members. You must receive all routine care from plan providers. Benefits, formulary, pharmacy network, provider network, premium, and/or co-payments/coinsurance may change on January 1 of each year. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, co-payments, and restrictions may apply. Other providers are available in our network.

© Samaritan Health Plans

Last modified: Nov. 20, 2014
H3811_MA4001_2014A CMS Approved 10/1/2014