Benefits
Your Coverage Information
The list of materials below are mailed to your home. If you need additional copies of your member materials, please contact Customer Service. For association members (Momentum Plans), please contact your employer or association for your materials.
- Medical/Pharmacy Policy
- Summary of Benefits and Coverage
- Glossary of Terms
- Vision Handbook (if applicable)
A List of Benefit Highlights
The benefits information provided is a brief summary and not a complete description of benefits. Limitations and exclusions apply. Please see your member policy (Medical and Pharmacy Handbook) for full details.
Summaries of Benefits and Coverage
Tier 1 - 20% Coinsurance
Performance Platinum $500
Performance Platinum $750
Performance Gold $1,000
Performance Gold $2,000
Performance Gold $3,000
Performance Silver $5,250
Performance Silver $6,850
Performance Silver $7,150
Performance Silver $7,350
Tier 2 - 30% Coinsurance
Performance Gold $500
Performance Gold $750
Performance Gold $1,000
Performance Gold $1,500
Performance Gold $2,000
Performance Silver $3,250
Performance Silver $3,500
Performance Silver $4,000
Performance Silver $5,000
Performance Silver $6,850
Performance Silver $7,150
Performance Silver $7,350
Tier 3- 50% Coinsurance
Performance Gold $500
Performance Gold $750
Performance Gold $1,000
Performance Silver $1,750
Performance Silver $2,000
Performance Silver $2,500
Performance Silver $3,000
Performance Silver $3,500
Performance Silver $4,000
Performance Silver $5,000
Performance Silver $6,850
Performance Silver $7,150
Performance Silver $7,350
Health Savings Account-Eligible
Performance Silver $2,700 HSA
Performance Silver $3,500 HSA
Performance Silver $4,000 HSA
Performance Bronze $6,750 HSA
Standard
Oregon Standard Silver
Oregon Standard Bronze
Basic
2018 Plan Summaries
For plans with an effective start date in 2018:
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
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
2017 Plan Summaries
For plans with an effective start date in 2017:
2017 Bronze Standard
2017 Silver Standard
2017 Health & Wellbeing 5000/60
2017 Health & Wellbeing 3000/20
2017 Health & Wellbeing 2500/20
2017 New Performance
2017 Small Group Benefit Exclusions
2017 Everyday Choices Option 1
2017 Everyday Choices Option 2
2017 Everyday Choices Basic
2017 Everyday Choices High Deductible Health Plan 2500
2017 Everyday Choices High Deductible Health Plan 5250
2017 Alternative Care Rider - Option 1
2017 Alternative Care Rider - Option 2
2017 Vision Plan
2017 Everyday Choices Benefit Exclusions
Momentum Plans - Please see your Association or employer
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.
2019 Authorization List
2019 Authorization List for all Small Group Plans
2019 Authorization List for Everyday Choices Plans
2019 Authorization List for Momentum Plans
2018 Authorization Lists
2018 Authorization List for Standard, New Performance PPO and Health & Wellbeing Plans
2018 Authorization List for Everyday Choices Plans
2018 Authorization List for Momentum Plans
2017 Authorization Lists
2017 Authorization List for Standard, New Performance PPO and Health & Wellbeing Plans
2017 Authorization List for Everyday Choices Plans
2017 Authorization List for 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.
Search 2018 Small Group Drug List
Search 2018 Large Group Drug List
2019 Covered Drug Lists
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
Certificates and Endorsements
2018 Documents
For plans with an effective start date in 2018:
2018 Small Group Certificate for Standard, New Performance PPO and Health & Wellbeing Plans
2018 Large Group Certificate for Everyday Choices Plans
2018 Momentum Certificate for Samaritan Momentum Plans
2017 Documents
For plans with an effective start date in 2017:
2017 Small Group Certificate for Standard, New Performance PPO and Health & Wellbeing Plans
2017 Large Group Certificate for Everyday Choices Plans
2017 Association Certificate for Samaritan Momentum Plans
2017 Large Group Endorsement - Summary of Changes
Talk with our Member Services representatives
Mon.–Fri.