2018 & 2019 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)

Looking for formularies or our pharmacy directory? Visit our prescription drug page.

Summaries
Prior Authorization
Certificates

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.

2020 Plans

Small Group Plan

For plans with an effective start date in 2020.

Summary of Benefits and Coverage

2019 Plans

Small Group Plan

For plans with an effective start date in 2019.

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

Performance 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

2018 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.