Benefits
Your 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)
Medical Benefits
The benefits information provided is a brief summary and not a complete description of benefits. Limitations and exclusions apply. Please see your Member Certificate for full details.
Small Group Plan
Summary of Benefits and Coverage
Tier 1 - 20% Coinsurance
Performance Platinum 500
Performance Gold 1000
Performance Gold 2000
Performance Gold 3150
Performance Gold 4000
Tier 2 - 30% Coinsurance
Performance Gold 500
Performance Gold 1000
Performance Gold 1500
Performance Gold 2500
Performance Silver 5000
Performance Silver 6850
Tier 3 - 50% Coinsurance
Performance Gold 500
Performance Gold 1000
Performance Silver 3100
Performance Silver 4000
Performance Silver 5000
Performance Silver 6850
High Deductible Health Plan
Performance Silver 2800 HDHP
Performance Silver 3500 HDHP
Performance Bronze 5000 HDHP
Performance Bronze 6850 HDHP
Standard
Oregon Standard Silver
Oregon Standard Bronze
Basic
Small Group Plan
Summary of Benefits and Coverage
Tier 1 - 20% Coinsurance
Performance Platinum 500
Performance Platinum 750
Performance Gold 1000
Performance Gold 2000
Performance Gold 3000
Performance Silver 5250
Performance Silver 6850
Performance Silver 7150
Performance Silver 7350
Tier 2 - 30% Coinsurance
Performance Gold 500
Performance Gold 750
Performance Gold 1000
Performance Gold 1500
Performance Gold 2000
Performance Silver 3250
Performance Silver 3500
Performance Silver 4000
Performance Silver 5000
Performance Silver 6850
Performance Silver 7150
Performance Silver 7350
Tier 3- 50% Coinsurance
Performance Gold 500
Performance Gold 750
Performance Gold 1000
Performance Silver 1750
Performance Silver 2000
Performance Silver 2500
Performance Silver 3000
Performance Silver 3500
Performance Silver 4000
Performance Silver 5000
Performance Silver 6850
Performance Silver 7150
Performance Silver 7350
Health Savings Account-Eligible
Performance Silver 2700 HSA
Performance Silver 3500 HSA
Performance Silver 4000 HSA
Performance Bronze 6750 HSA
Standard
Oregon Standard Silver
Oregon Standard Bronze
Basic
Large Group Plan
Benefit Summaries and Riders
2019 Everyday Choices Option 1
2019 Everyday Choices Option 2
2019 Everyday Choices Basic
2019 Everyday Choices HSA 2500
2019 Everyday Choices HSA 2700
2019 Everyday Choices HSA 5250
2019 Alternative Care Rider - Option 1
2019 Alternative Care Rider - Option 2
2019 Vision Plan
Additional Benefit Information
Women’s Reproductive Health Services
Hearing Services - Everyday Choices and Momentum plans
Small Group Plan
For plans with an effective start date in 2018.
Benefit Schedules
2018 Health & Wellbeing 2500
2018 Health & Wellbeing 3000
2018 Health & Wellbeing 5000
2018 Samaritan Oregon Standard Bronze
2018 Samaritan Oregon Standard Silver
2018 New Performance
Summary of Benefits and Coverage
2018 SBC Health & Wellbeing 2500
2018 SBC Health & Wellbeing 3000
2018 SBC Health & Wellbeing 5000
2018 SBC Samaritan Oregon Standard Bronze
2018 SBC Samaritan Oregon Standard Silver
2018 SBC New Performance
Large Group Plan
For plans with an effective start date in 2018.
2018 Everyday Choices Option 1
2018 Everyday Choices Option 2
2018 Everyday Choices Basic
2018 Everyday Choices High Deductible Health Plan 2500
2018 Everyday Choices High Deductible Health Plan 5250
2018 Alternative Care Rider - Option 1
2018 Alternative Care Rider - Option 2
2018 Vision Plan
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.
2020 Authorization List
2020 Authorization List - Standard and Performance Plans
2020 Authorization List - Everyday Choices Plans
2020 Authorization List - Momentum Plans
2019 Authorization List
2019 Authorization List - Standard and Performance Plans
2019 Authorization List - Everyday Choices Plans
2019 Authorization List - Momentum Plans
2018 Authorization Lists
2018 Authorization List - Standard, Performance and Health & Wellbeing Plans
2018 Authorization List - Everyday Choices Plans
2018 Authorization List - Momentum Plans
List of Covered Drugs
Our large and small group plans use comprehensive formularies — a list of drugs covered by the plan — to meet members needs. The formularies do not contain the names of all medications available in the market. If a medication is not listed, please contact Customer Service for assistance at 800-832-4580 (TTY 800-735-2900), from 8 a.m. to 8 p.m., Mon.-Fri.
For Standard and Performance Plans:
For Everyday Choices and Momentum Plans:
2019 Covered Drug Lists
2019 Formulary - Standard and Performance Plans
2019 Formulary Changes - Standard and Performance Plans
2019 Formulary - Everyday Choices and Momentum Plans
2019 Formulary Changes - Everyday Choices and Momentum Plans
Network Pharmacies
We offer an extensive network of pharmacies throughout the state of Oregon. Plus, our network includes chain pharmacies throughout the nation to use when you travel out of state. This directory applies to both small and large group plans. Please be aware that pharmacy information may change at any time.
Mail Order
Report a Drug Price Increase
Certificates and Endorsements
2019 Documents
For plans with an effective start date in 2019:
2019 Certificate - Performance Plans
2019 Certificate - Standard Bronze Plans
2019 Certificate - Standard Silver Plans
2018 Documents
For plans with an effective start date in 2018:
2018 Certificate - Standard, Performance and Health & Wellbeing Plans
2018 Certificate - Everyday Choices Plans