Medicare Resources

Download plan documents and forms to help you serve your clients interested in our Samaritan Advantage plans. Can’t find something? Contact us to let us know what you need.

Enrollment Documents

Pre-enrollment Checklist
Enrollment Form Instructions
2022 Enrollment Form
2021 Enrollment Form
Scope of Appointment Form

Completed forms may be faxed directly to our Enrollment Department at 541-768-9778 or emailed to SHPOMemberEnrollment@samhealth.org. 

It is expected that the agent’s received date(s) for the completed enrollment form and completed scope of appointment form each be documented on the forms in order to be compliant.

2022 Plan Documents

2022 Plans Overview
2022 Low Income Subsidy Premium Summary
2022 Summary of Benefits - Conventional, Premier & Premier Plus Plan
2022 Prior Authorization List
2022 Over-the-Counter Drug List
Nondiscrimination Notice
Multi-Language Interpreter Services
2022 Star Ratings
24/7 Nurse Line
Provider Directory (To find a dental provider, choose any dental provider who has not opted-out of participating in Medicare programs. Review CMS Opt-Out List.)
All 2022 plan documents

2021 Plan Documents

2021 Plan Comparison Guide
2021 Extra Help
2021 Summary of Benefits – Conventional Plan
2021 Summary of Benefits – Premier & Premier Plus Plan
2021 Prior Authorization List
Nondiscrimination Notice
Multi-Language Interpreter Services
2021 Star Ratings
24/7 Nurse Line
Provider Directory (To find a dental provider, choose any dental provider who has not opted-out of participating in Medicare programs. Review CMS Opt-Out List.)
All 2021 plan documents

2020 Plan Documents

2020 Plan Comparison Guide
2020 Extra Help
2020 Summary of Benefits
2020 Prior Authorization List
Nondiscrimination Notice
Multi-Language Interpreter Services
Star Ratings
24/7 Nurse Line
Provider Directory (To find a dental provider, choose any dental provider who has not opted-out of participating in Medicare programs. Review CMS Opt-Out List.)
All 2020 plan documents