2020 Benefits
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Coverage Information
Below you can find your plan documents. If you need additional copies of your member materials, please contact your employer or association for your materials. Learn how to make the most of your benefits.
- Medical/Pharmacy Certificate
- Summary of Benefits and Coverage
- Riders
- Vision Certificate (if applicable)
Plans for 1–50 Employees
Samaritan Health Plans offers small group plans for Oregon businesses with 1–50 employees. Our integrated health plans and wellness programs help hold the line on your insurance costs by engaging employees and their families in maintaining and improving their health. Our plans include:
- A local provider network
- Free preventive services
- Wellness services — includes a health assessment, biometric screening and online health courses (these services not available with Standard plans)
Certificate
For plans with an effective start date in 2021 review the 2020 Certificate - Small Group Plans.
Some Services Require Authorization
Coverage of certain medical services and surgical procedures requires Samaritan Health Plans’ written authorization before the services are performed. Your provider can request prior authorization by phone, fax or mail. If for any reason your provider will not or does not request prior authorization for you, you must contact Samaritan Health Plans yourself. In some cases, additional information or a second opinion can be required before authorizing coverage. Review the 2020 Authorization List - Small Group Plans.
Benefit Summaries
The deductibles and out-of-pocket maximums listed below reflect costs for individuals using in-network providers. Costs will be higher when using out-of-network providers. Please refer to the plan documents for a full description of benefits.
The deductibles and out-of-pocket maximums listed below reflect costs for individuals using in-network providers. Costs will be higher when using out-of-network providers. Please refer to the plan documents for a full description of benefits.
| Deductible | Out-of-pocket Maximum | Coinsurance | Office Visits | Urgent Care | Emergency Care | Plan Documents | |
|---|---|---|---|---|---|---|---|
| Samaritan Standard Bronze Plan | $7,900 | $7,900 | 0% | Primary care: $45 Specialty care: $90 Mental health: $45 |
0% coinsurance | 0% coinsurance | Summary of Benefits and Coverage - Bronze Schedule of Benefits - Bronze |
| Samaritan Standard Silver Plan | $3,550 | $8,150 | 30% | Primary care: $40 Specialty care: $80 Mental health: $40 |
30% coinsurance | 30% coinsurance |
Summary of Benefits and Coverage - Silver |
The deductibles and out-of-pocket maximums listed below reflect costs for individuals using in-network providers. Costs will be higher when using out-of-network providers. Please refer to the plan documents for a full description of benefits.
| Deductible | Out-of-pocket Maximum | Coinsurance | Office Visits | Urgent Care | Emergency Care | Plan Documents | |
|---|---|---|---|---|---|---|---|
| Performance Bronze Basic | $8,150 | $8,150 | 0% | Primary care, specialty care and mental health: 0%, deductible applies |
0% coinsurance | 0% coinsurance | Summary of Benefits and Coverage - Bronze Basic Schedule of Benefits - Bronze Basic |
The deductibles and out-of-pocket maximums listed below reflect costs for individuals using in-network providers. Costs will be higher when using out-of-network providers. Please refer to the plan documents for a full description of benefits.
| Deductible | Out-of-pocket Maximum | Coinsurance | Office Visits | Urgent Care | Emergency Care | Plan Documents | |
|---|---|---|---|---|---|---|---|
| Performance Platinum 500 | $500 | $3,000 | 20% | Primary care: $15 Specialty care: $30 Mental health: $15 |
$30 | $200* | Summary of Benefits and Coverage -Performance Platinum 500 Tier 1 Schedule of Benefits - Platinum 500 |
| Performance Gold 1000 | $1,000 | $8,150 | 20% | Primary care: $15 Specialty care: $30 Mental health: $15 |
$30 | $300* | Summary of Benefits and Coverage - Performance Gold 1000 Tier 1 Schedule of Benefits - Gold 1000 |
| Performance Gold 2000 | $2,000 | $8,150 | 20% | Primary care: $25 Specialty care: $45 Mental health: $25 |
$45 | $300* | Summary of Benefits and Coverage - Performance Gold 2000 Tier 1 Schedule of Benefits - Gold 2000 |
| Performance Gold 3150 | $3,150 | $8,150 | 20% | Primary care: $25 Specialty care: $45 Mental health: $25 |
$45 | $300* | Summary of Benefits and Coverage - Performance Gold 3150 Tier 1 Schedule of Benefits - Gold 3150 |
| Performance Gold 4000 | $4,000 | $6,500 | 20% | Primary care: $25 Specialty care: $45 Mental health: $25 |
$45 | $300* | Summary of Benefits and Coverage - Performance Gold 4000 Tier 1 Schedule of Benefits - Gold 4000 |
*Copay and coinsurance apply after deductible
The deductibles and out-of-pocket maximums listed below reflect costs for individuals using in-network providers. Costs will be higher when using out-of-network providers. Please refer to the plan documents for a full description of benefits.
| Deductible | Out-of-pocket Maximum | Coinsurance | Office Visits | Urgent Care | Emergency Care | Plan Documents | |
|---|---|---|---|---|---|---|---|
| Performance Gold 500 | $500 | $4,500 | 30% | Primary care: $40 Specialty care: $60 Mental health: $40 |
$60 | $400* |
Summary of Benefits and Coverage - Gold 500 |
| Performance Gold 1000 | $1,000 | $8,150 | 30% | Primary care: $40 Specialty care: $60 Mental health: $40 |
$60 | $400* | Summary of Benefits and Coverage - Performance Gold 1000 Schedule of Benefits - Gold 1000 |
| Performance Gold 1500 | $1,500 | $8,150 | 30% | Primary care: $40 Specialty care: $60 Mental health: $40 |
$60 | $400* | Summary of Benefits and Coverage - Performance Gold 1500 Schedule of Benefits - Gold 1500 |
| Performance Gold 2500 | $2,500 | $6,200 | 30% | Primary care: $40 Specialty care: $60 Mental health: $40 |
$60 | $400* | Summary of Benefits and Coverage - Performance Gold 2500 Schedule of Benefits - Gold 2500 |
| Performance Silver 5000 | $5,000 | $8,150 | 30% | Primary care: $40 Specialty care: $60 Mental health: $40 |
$60 | $400* | Summary of Benefits and Coverage - Performance Silver 5000 Schedule of Benefits - Silver 5000 |
| Performance Silver 6850 | $6,850 | $8,150 | 30% | Primary care: $40 Specialty care: $60 Mental health: $40 |
$60 | $400* | Summary of Benefits and Coverage - Silver 6850 Schedule of Benefits - Silver 6850 |
*Copay and coinsurance apply after deductible
The deductibles and out-of-pocket maximums listed below reflect costs for individuals using in-network providers. Costs will be higher when using out-of-network providers. Please refer to the plan documents for a full description of benefits.
| Deductible | Out-of-pocket Maximum | Coinsurance | Office Visits | Urgent Care | Emergency Care | Plan Documents | |
|---|---|---|---|---|---|---|---|
| Performance Gold 500 | $500 | $5,750 | 50% | Primary care: $50 Specialty care: $70 Mental health: $50 |
$70 | $500* | Summary of Benefits and Coverage - Gold 500 Schedule of Benefits - Gold 500 |
| Performance Gold 1000 | $1,000 | $5,750 | 50% | Primary care: $50 Specialty care: $70 Mental health: $50 |
$70 | $500* | Summary of Benefits and Coverage - Gold 1000 Schedule of Benefits - Gold 1000 |
| Performance Silver 3100 | $3,100 | $8,150 | 50% | Primary care: $50 Specialty care: $70 Mental health: $50 |
$70 | $500* | Summary of Benefits and Coverage - Silver 3100 Schedule of Benefits - Silver 3100 |
| Performance Silver 4000 | $4,000 | $8,150 | 50% | Primary care: $50 Specialty care: $70 Mental health: $50 |
$70 | $500* | Summary of Benefits and Coverage - Silver 4000 Schedule of Benefits - Silver 4000 |
| Performance Silver 5000 | $5,000 | $8,150 | 50% | Primary care: $50 Specialty care: $70 Mental health: $50 |
$70 | $500* | Summary of Benefits and Coverage - Silver 5000 Schedule of Benefits - Silver 5000 |
| Performance Silver 6850 | $6,850 | $8,150 | 50% | Primary care: $50 Specialty care: $70 Mental health: $50 |
$70 | $500* | Summary of Benefits and Coverage - Silver 6850 Schedule of Benefits - Silver 6850 |
*Copay and coinsurance apply after deductible
The deductibles and out-of-pocket maximums listed below reflect costs for individuals using in-network providers. Costs will be higher when using out-of-network providers. Please refer to the plan documents for a full description of benefits.
| Deductible | Out-of-pocket Maximum | Coinsurance | Office Visits | Urgent Care | Emergency Care | Plan Documents | |
|---|---|---|---|---|---|---|---|
| Performance Silver 2800 HDHP | $2,800 | $6,850 | 20% | Primary care: 20% Specialty care: 20% Mental health: 20% |
20% | 20% | Summary of Benefits and Coverage - Silver 2800 Schedule of Benefits - Silver 2800 |
| Performance Silver 3500 HDHP | $3,500 | $6,850 | 20% | Primary care: 20% Specialty care: 20% Mental health: 20% |
20% | 20% | Summary of Benefits and Coverage - Silver 3500 Schedule of Benefits - Silver 3500 |
| Performance Bronze 5000 HDHP | $5,000 | $6,850 | 20% | Primary care: 20% Specialty care: 20% Mental health: 20% |
20% | 20% | Summary of Benefits and Coverage - Bronze 5000 Schedule of Benefits - Bronze 5000 |
| Performance Bronze 6850 HDHP | $6,850 | $6,850 | 0% | Primary care: 0% Specialty care: 0% Mental health: 0% |
0% | 0% | Summary of Benefits and Coverage - Bronze 6850 Schedule of Benefits - Bronze 6850 |
Plans for 51+ Employees
Samaritan Health Plans offers large group plans for Oregon businesses with more than 50 employees. Our integrated health plans and wellness programs help hold the line on your insurance costs by engaging employees and their families in maintaining and improving their health. All of our plans include:
- A nationwide provider network
- Free preventive services
- Wellness services (includes a health assessment, biometric screening and online health courses)
Certificate
For plans with an effective start date in 2021 review the 2020 Certificate - Large Group Plans.
Some Services Require Authorization
Coverage of certain medical services and surgical procedures requires Samaritan Health Plans’ written authorization before the services are performed. Your provider can request prior authorization by phone, fax or mail. If for any reason your provider will not or does not request prior authorization for you, you must contact Samaritan Health Plans yourself. In some cases, additional information or a second opinion can be required before authorizing coverage. Review the 2020 Authorization List - Large Group Plans.
Additional Benefits Available
Our large group plans can be customized with the following optional benefits:
- Alternative Care (including chiropractic, acupuncture and massage services):
Alternative Care Option 1 or Alternative Care Option 2 - Vision Coverage:
Vision Benefits - Employee Assistance Program (EAP):
EAP Enhanced, EAP Enhanced WholeLife Directions, EAP Platform or EAP Platform WholeLife Directions
Schedule of Benefits
The deductibles and out-of-pocket maximums listed below reflect costs for individuals using in-network providers. Costs will be higher when using out-of-network providers. Please refer to the plan documents for a full description of benefits.
| Deductible | Out-of-pocket Maximum | Coinsurance | Office Visits | Urgent Care | Plan Documents | |
|---|---|---|---|---|---|---|
| Everyday Choices Option 1 | [$0–$8,150] | [$0–$8,150] | 10–50% | Primary care: $20 Specialty care: $35 Mental health: $35 |
$35 | Schedule of Benefits - Option 1 |
| Everyday Choices Option 2 | [$0–$8,150] | [$0–$8,150] | 10–50% | Primary care: $30 Specialty care: $45 Mental health: $45 |
$45 | Schedule of Benefits - Option 2 |
| Everyday Choices Option 3 | [$0–$8,150] | [$0–$8,150] | 10–50% | Primary care: $35 Specialty care: $50 Mental health: $30 |
$50 | Schedule of Benefits - Option 3 |
| Everyday Choices HDHP 2500 | $2,500 | $6,750 | 20% | Primary care: 20% Specialty care: 20% Mental health: 20% |
20% coinsurance | Schedule of Benefits - HDHP 2500 |
| Everyday Choices HDHP 2700 | $2,700 | $6,750 | 20% | Primary care: 20% Specialty care: 20% Mental health: 20% |
20% coinsurance | Schedule of Benefits - HDHP 2700 |
| Everyday Choices HDHP 5250 | $5,250 | $6,750 | 20% | Primary care: 20% Specialty care: 20% Mental health: 20% |
20% coinsurance | Schedule of Benefits - HDHP 5250 |