- Members Overview
- Medicare Members
- 2021 Benefits
2021 Benefits
Bi-Mart Pharmacies Are Closed
Your prescriptions have been moved to Walgreens unless you already switched locations.
Your Coverage Information
If you need additional copies of your member materials, please contact Customer Service.
Medical Coverage Information
Select your plan below to see an overview of your plan’s benefits and download your member materials.
Coverage of certain medical services and surgical procedures requires Samaritan Advantage Health Plans’ written authorization before the services are performed.
Note: Conventional Plan members may not be allowed to sign up for a Part D prescription drug plan.
2021 Summary of Benefits - Conventional Plan
2021 Evidence of Coverage - Conventional Plan
2021 Annual Notice of Changes - Conventional Plan
2021 Prior Authorization List
| Conventional Plan (HMO) - $70/mo. | |
|---|---|
| Deductible | $0 annual deductible |
| Medical Out-Of-Pocket Maximum | $4,600 is the most you will pay per year for medical copays and coinsurance that apply to your out-of-pocket max |
| Doctor Office Visits | $10 copay per primary care visit $20 copay per specialist visit |
| Inpatient Hospital Care | $350 copay per day for days 1–5 $0 copay after day 5 |
| Urgent Care — Nationwide | $25 copay per urgent care visit |
| Emergency Care — Worldwide | $90 copay per emergency care visit ($0 copay if you are admitted to the hospital within 24 hours) |
| Ambulance | $250 copay per one-way trip by ground |
| Air Ambulance | 20% coinsurance |
| Outpatient Hospital Services | $150 copay per outpatient surgery |
| Skilled Nursing Facility Care | $0 copay per day for days 1–20 $165 copay per day for days 21–45 $0 copay per day for days 46–100 |
| Vision Services | $20 copay per visit for exams to diagnose and
treat conditions and diseases of the eye $20 copay per visit for routine eye exam (1 per year) $125 limit per calendar year for eyewear |
| Chiropractic | $20 copay per visit for manual manipulation
of the spine to correct subluxation $25 copay per visit for routine chiropractic with up to 5 visits per year |
| Acupuncture |
$20 copay per acupuncture visit with up to 30 visits per year |
| Annual Physical Exams | $0 copay per exam |
| Dental Services | $20 copay per preventive visit (up to 2 oral
exams and 2 regular cleanings per year) $0 copay for dental X-rays (1 set per calendar year) |
| Fitness Benefit | $0 gym membership to SamFit |
Coverage of certain medical services and surgical procedures requires Samaritan Advantage Health Plans’ written authorization before the services are performed.
2021 Summary of Benefits - Premier Plan
2021 Evidence of Coverage - Premier Plan
2021 Annual Notice of Changes - Premier Plan
2021 Prior Authorization List
| Premier Plan (HMO) - $35/mo. | |
|---|---|
| Deductible | $0 annual deductible |
| Medical Out-Of-Pocket Maximum | $4,600 is the most you will pay per year for medical copays and coinsurance that apply to your out-of-pocket max |
| Doctor Office Visits | $10 copay per primary care visit $30 copay per specialist visit |
| Inpatient Hospital Care | $350 copay per day for days 1–5 $0 copay per day for days 6–90 |
| Urgent Care — Nationwide | $35 copay per urgent care visit |
| Emergency Care — Worldwide | $90 copay per emergency care visit ($0 copay if you are admitted to the hospital within 24 hours) |
| Ambulance | $250 copay per one-way trip by ground |
| Air Ambulance | 20% coinsurance |
| Skilled Nursing Facility Care | $0 copay per day for days 1–20 $165 copay per day for days 21–45 $0 copay per day for days 46–100 |
| Chiropractic | $20 copay per visit for manual manipulation
of the spine to correct subluxation $25 copay per visit for routine chiropractic with up to 5 visits per year |
| Acupuncture | $20 copay per acupuncture visit with up to 30 visits per year |
| Annual Physical Exams | $0 copay per exam |
| Outpatient Hospital Services | $200 copay per outpatient surgery |
| Vision Services | $30 copay per visit for exams to diagnose and
treat conditions and diseases of the eye $0 copay per visit for routine eye exam (1 per year) $125 limit per calendar year for eyewear |
Coverage of certain medical services and surgical procedures requires Samaritan Advantage Health Plans’ written authorization before the services are performed.
2021 Summary of Benefits - Premier Plan Plus
2021 Evidence of Coverage - Premier Plan Plus
2021 Annual Notice of Changes - Premier Plan Plus
2021 Prior Authorization List
| Premier Plan Plus (HMO) - $129/mo. | |
|---|---|
| Deductible | $0 annual deductible |
| Medical Out-Of-Pocket Maximum | $4,600 is the most you will pay per year for medical copays and coinsurance that apply to your out-of-pocket max |
| Doctor Office Visits | $5 copay per primary care visit $30 copay per specialist visit |
| Inpatient Hospital Care | $325 copay per day for days 1–5 $0 copay per day for days 6–90 |
| Urgent Care — Nationwide | $35 copay per urgent care visit |
| Emergency Care — Worldwide | $90 copay per emergency care visit ($0 copay if you are admitted to the hospital within 24 hours) |
| Ambulance | $250 copay per one-way trip by ground |
| Air Ambulance | 20% coinsurance |
| Skilled Nursing Facility Care | $0 copay per day for days 1–20 $160 copay per day for days 21–60 $0 copay per day for days 61–100 |
| Chiropractic | $20 copay per visit for manual manipulation
of the spine to correct subluxation $25 copay per visit for routine chiropractic with up to 5 visits per year |
| Acupuncture | $20 copay per acupuncture visit with up to 30 visits per year |
| Annual Physical Exams | $0 copay per exam |
| Outpatient Hospital Services | 15% coinsurance per outpatient surgery |
| Fitness Benefit | No-cost Silver&Fit® membership |
| Vision Services | $30 copay per visit for exams to diagnose and
treat conditions and diseases of the eye $30 copay per visit for routine eye exam (1 per year) $125 limit per calendar year for eyewear |
| Dental Services | $25 copay per preventive visit (up to 2 oral exams and 2 regular cleanings per year) $0 copay for dental X-rays (1 set per calendar year) $1,000 limit per calendar year for comprehensive dental services such as crowns, fillings and extractions |
| Hearing Aids and Equipment | $500 limit per calendar year for hearing aids and equipment |
Coverage of certain medical services and surgical procedures requires Samaritan Advantage Health Plans’ written authorization before the services are performed.
2021 Summary of Benefits - Special Needs Plan (updated 12/1/2020)
2021 Evidence of Coverage - Special Needs Plan (updated 12/1/2020)
2021 Annual Notice of Changes - Special Needs Plan (updated 12/1/2020)
2021 Over-the-Counter (OTC) Benefits
2021 Prior Authorization List
What Are My Supplemental Dental Benefits?
Samaritan’s Conventional and Premier Plus Advantage Plans offer the following supplemental dental benefits per calendar year (these benefits are not available to Premier Plan members):
| Conventional Plan | Premier Plan | Premier Plan Plus | |
|---|---|---|---|
Preventive Dental Benefits
|
$0 copay for dental x-rays $20 copay for each preventive dental visit |
Not available |
$0 copay for dental x-rays $25 copay for each preventive dental visit |
| Comprehensive Dental Benefits
Use for fillings, extractions, crowns, etc. |
Not available | Not available | $1,000 limit. Orthodontia is not covered |
How Do I Find a Dental Provider & Obtain Services?
- Contact our contracted dental provider, or
- Many other dentists who have not opted out of Medicare will accept Samaritan Advantage. If you need assistance locating a dental provider who has not opted out of Medicare, call a Customer Service team member at 541-768-4550, toll free 800-832-4580, (TTY 800-735-2900) to find one near you.
How Do I Get Reimbursed?
If you had to pay out of pocket, please follow the steps below to get reimbursed* (except for copays):
- Prior to your appointment, print a Member Reimbursement Claim form.
- Take it with you to your appointment.
- Before you leave the office, obtain a completed ADA Claim form or an itemized statement that meets all the documentation requirements listed on the form and a receipt showing that you have paid.
- Completely fill out the Member Reimbursement Claim form.
- Attach the itemized statement and a copy of your receipt or cancelled check.
- Follow the instructions on the Member Reimbursement Claim form for submitting your documentation.
- Please allow 30 days from the day we receive your claim for us to process your request.
What If I Have More Questions?
Our Customer Service Team is happy to help. Call us at 541-768-4550 or toll free 800-832-4580, (TTY 800-735-2900). We are here to serve you.
Customer Service is available:
- Oct. 1 to March 31: Daily, from 8 a.m. to 8 p.m.
- April 1 to Sept. 30: Monday through Friday, from 8 a.m. to 8 p.m.
*Samaritan Advantage cannot reimburse for services rendered by providers who have opted-out of Medicare. Reimbursement for services is subject to what is submitted with the claim and all requirements described in the Evidence of Coverage.
Medicare Part D Prescription Drugs
A formulary is a list of covered drugs selected by Samaritan Advantage Health Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the year. See drug list limits and requirements for definitions of terms found in your formulary.
Understanding Your Drug Coverage
Samaritan Advantage’s Premier Plan HMO and Samaritan Advantage Premier Plan Plus HMO combine a prescription drug plan with a medical benefits package that covers more than original Medicare with less out-of-pocket expenses for you. Members with Low Income Subsidy are subject to different cost shares. Members with Premier Plan coverage who receive Extra Help from Medicare will have an $92 deductible for Tiers 3, 4 and 5.
| Premier Plan (HMO) | Premier Plan Plus (HMO) | |
|---|---|---|
| Annual Deductible Phase | $200 (only applies to Tiers 3, 4 and 5)* | $0 |
| Initial Coverage Phase (You begin the calendar year paying these cost shares.) |
Tier 1: Maximum $3 copay Tier 2: Maximum $9 copay for generic formulary drugs Tier 3: Maximum $47 copay for preferred brand drugs Tier 4: Maximum $100 copay for non-preferred brand drugs Tier 5: 29% coinsurance for specialty drugs Tier 6: $0 copay Select Care Drugs |
Tier 1: Maximum $3 copay Tier 2: Maximum $9 copay for generic formulary drugs Tier 3: Maximum $47 copay for preferred brand drugs Tier 4: Maximum $100 copay for non-preferred brand drugs Tier 5: 33% coinsurance for specialty drugs Tier 6: $0 copay Select Care Drugs |
| Coverage Gap Phase (If you and the Plan pay a combined yearly total of $4,130 for prescription drugs, you enter the Coverage Gap Phase.) |
25% coinsurance for generic drugs 25% coinsurance for brand drugs |
No more than $9 copay for generic drugs 25% coinsurance for brand drugs |
| Catastrophic Phase (If your out-of-pocket costs and the amount discounted by brand drug manufacturers total $6,550, you enter the Catastrophic Coverage Phase.) |
The greater of $3.70 copay (generics), $9.20 copay (brands) or 5% coinsurance | The greater of $3.70 copay (generics), $9.20 copay (brands) or 5% coinsurance |
*Members with Premier Plan coverage who are also receiving “Extra Help” from Medicare will have a $92 deductible for Tiers 3, 4 and 5.
Most Medicare drugs
are covered; mail order service
available; 1-3 month supply
available.
Important Notice Regarding Discounts
A change in the law requires companies that make brand-name prescription drugs to give a discount on those drugs to Medicare. Beginning January 1, 2011, prescription drugs made and sold by companies that have not agreed to give a discount to Medicare can no longer be covered (paid for) by Medicare Prescription Drug Plans.
For additional help, visit the Medicare Prescription Drug Plan Finder at www.medicare.gov.
If you qualify for the Low Income Subsidy (also called “Extra Help") with your Medicare prescription drug plan costs, your premium and costs at the pharmacy will be lower. When you join one of our plans, Medicare will tell us how much Extra Help you are getting. Then we will let you know the amount you will pay. See the table below for the monthly premiums for the current year.
How to Inquire About Low Income Subsidy
If you are not getting Extra Help, you can see if you qualify by calling Social Security at 800-772-1213 (TTY users should call 800-325-0778) or visit www.socialsecurity.gov.
2021 Monthly Premiums
The following chart outlines the premium amounts based on the various Low Income Subsidy levels.
| Conventional Plan ($70/month) |
Premier Plan ($35/month) |
Premier Plan Plus ($129/month) |
|
|---|---|---|---|
| 25% Low Income Subsidy (LIS) | N/A | You pay $26.20* | You pay $120* |
| 50% Low Income Subsidy (LIS) | N/A | You pay $17.50* | You pay $111* |
| 75% Low Income Subsidy (LIS) | N/A | You pay $8.70* | You pay $102* |
| 100% Low Income Subsidy (LIS) | N/A | You pay $0* | You pay $93* |
* The premiums listed above include both medical service and prescription drug benefits. These premiums do not include any Medicare Part B premium you may have to pay.
2021 Cost-Sharing
Standard Retail Cost-Sharing (in-network) - up to a 34-day supply
For generic/preferred multi-sourced drugs, you pay either a $0, $1.30, $3.70 or 15% copay per prescription. For all other drugs, you pay either a $0, $4.00, $9.20 or 15% copay per prescription.
Long-term Care (LTC) Cost-Sharing - up to a 31-day supply
For generic/preferred multi-sourced drugs, you pay either a $0, $1.30, $3.70 or 15% copay per prescription. For all other drugs, you pay either a $0, $4.00, $9.20 or 15% copay per prescription.
See also the Centers for Medicare and Medicaid Services (CMS) Best Available Evidence Policy.
In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Quantity limitations and restrictions may apply.
A network pharmacy is one that we have made arrangements for them to provide prescription drugs to plan members. These pharmacies are where members can obtain prescription drug benefits provided by Samaritan Advantage Premier Plan HMO, Samaritan Advantage Premier Plan Plus HMO, and Samaritan Advantage Special Needs Plan HMO. Samaritan Health Plans has an arrangement with pharmacies across the United States, which consists of approximately 90 percent of pharmacies. This equals or exceeds Centers for Medicare & Medicaid Services (CMS) requirements for pharmacy access in your area. In most cases, your prescriptions are covered if they are filled at a network pharmacy.
ADOBE READER SEARCH TIPS for your Pharmacy Directory
Once you have opened the link to the Pharmacy Directory found below, you can search the document for a specific network pharmacy. Just hold down the Crtl + f keys on your keyboard to use the “Find” function within Adobe Reader, then type in the name of the facility or provider you are seeking.
2021 Pharmacy Directory (Updated 12/07/2021)
You may also search our nationwide pharmacy directory through OptumRx’s Pharmacy Locator.
Once you go to a network pharmacy, you are not required to continue going to the same pharmacy to fill your prescription, you can go to any of our network pharmacies.
Bi-Mart pharmacies in Oregon are closed. Bi-Mart has transferred current patient prescriptions to Walgreens pharmacies.
Please refer to the following regarding where your prescriptions have been transferred:
- Bi-Mart Pharmacy #606 - Albany (2272 Santiam Hwy SE) is closed. Prescriptions have been transferred to Walgreens Pharmacy #6530 at 1700 Pacific Blvd. SE, Albany.
- Bi-Mart Pharmacy #604 – Corvallis (2045 NW 9th Street) is closed. Prescriptions have been transferred to Walgreens Pharmacy #639 at 1555 SW 53rd Street, Corvallis.
- Bi-Mart Pharmacy #639 – Corvallis (1555 SW 53rd Street) is open and has become a Walgreens. Your prescriptions will remain at this location.
- Bi-Mart Pharmacy #665 – Lebanon (2680 S. Santiam Hwy) is closed. Prescriptions have been transferred to Walgreens Pharmacy #11399 at 3300 Burdell Blvd., Lebanon.
- Bi-Mart Pharmacy #682 - Lincoln City (1030 SE Oar Avenue) is closed. Prescriptions have been transferred to Walgreens Pharmacy #9875 at 4048 N.E. Highway 101, Lincoln City.
- Bi-Mart Pharmacy #685 – Sweet Home (1980 Main Street) is closed. Prescriptions have been transferred to Walgreens Pharmacy #11399 at 3300 Burdell Blvd., Lebanon.
There is no action required unless you prefer not to use Walgreens for your prescriptions.
Out-of-Network Coverage
In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:
- If you are unable to obtain a covered drug in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24 hour service.
- If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail pharmacy (including high cost and unique drugs).
- If you are getting a vaccine that is medically necessary but not covered by Medicare Part B and some covered drugs that are administered in your doctor’s office.
Before you fill your prescription in any of these situations, call Customer Service at
If you do go to an out-of-network pharmacy for the reasons listed above, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. You can ask us to reimburse you for our share of the cost by submitting this form:
For certain kinds of drugs, members can get prescription drugs shipped to their homes through an in-network mail order pharmacy. Our plan’s mail-order service requires you to order a 90-day supply. You can find a list of in-network mail order pharmacies in your pharmacy directory.
Local provider
You can order your prescriptions for rapid mail delivery from Samaritan Health Services:
Samaritan Pharmacy - Corvallis
3251 NW Samaritan Drive, Suite 202, Corvallis
Phone: 541-768-5225
Refill line: 541-768-5230
If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. When possible, take along all the medication you will need. You can call Customer Service at 541-768-4550, 800-832-4580 (TTY 800-735-2900), from 8 a.m. to 8 p.m. daily to find out if there is a network pharmacy in the area where you are traveling. If there are no network pharmacies in that area, Customer Service may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy.
If you are traveling within the United States and territories and become ill, or lose or run out of your prescription drugs you may call Customer Service to find out if there is a network pharmacy in the area where you are traveling. If there are no network pharmacies in that area, Customer Service may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy. We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.
You can also use our pharmacy directory to find an in-network nationwide pharmacy near you. We will cover prescriptions that are filled at an out-of-network pharmacy if you are unable to locate an in-network option. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. You can ask us to reimburse you for our share of the cost by submitting this form:
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members. Examples of utilization management tools are described below:
Prior Authorization
We require you to get prior authorization for certain drugs. This means that you, your authorized representative, or your provider will need to get approval from us before you fill your prescription. Without approval, we may not cover the drug.
Premier and Premier Plan Plus Prior Authorization Criteria (updated 12/1/2021)
Special Needs Plan Prior Authorization Criteria (updated 12/1/2021)
Quantity Limits
For certain drugs we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, Samaritan Advantage Premier Plan provides 30 tabs per 30 days per prescription of Trintellix. This may be in addition to a standard one-month or three-month supply.
Premier and Premier Plan Plus Quantity Limit Criteria (updated 12/1/21)
Special Needs Plan Quantity Limit Criteria (updated 12/1/2021)
Step Therapy
In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.
Premier and Premier Plan Plus Step Therapy Criteria (updated 12/1/2021)
Special Needs Plan Step Therapy Criteria (updated 12/1/2021)
Part B vs. Part D
For drugs with a Part B versus D these drugs may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
Morphine Equivalent Dose (MED)
Morphine Equivalent Dose (MED) is a tool used to equate many different opioids into one standard value for the means of comparison. This standard value is based on the drug Morphine and its potency. Knowing the MED helps determine if a patient’s opioid doses are excessive and is useful if converting from one opioid to another. For opiate medications, MED limits apply and exceeding the plan limits will require an exception.
You can find out if your drug is subject to these additional requirements or limits by searching the formulary. If your drug does have these additional restrictions or limits, you can ask us to make an exception to our coverage rules.
You, your representative, or your prescriber can submit a medication exception / prior authorization if:
- Your drug has one or more additional requirements defined above.
- Your drug is not on the plan formulary.
- You would like the plan to lower the Tier for your drug.
To request an exception, you, your authorized representative, or the prescribing physician have the following options:
- Call Customer Service at 800-832-4580 (toll-free) or TTY 800-735-2900, daily from 8 a.m. to 8 p.m.
- OR - - Complete a Medication Exception / Prior Authorization Form (authorized representatives must also complete an Appointment of Representative Form) and submit to us:
Mail:
Samaritan Advantage Health Plan HMO
P.O Box 1310
Corvallis, OR 97339
Fax:
844-611-3831
Deliver:
Samaritan Health Plans
2300 NW Walnut Blvd., Corvallis
Monday - Friday, 8 a.m. to 5 p.m.
Expedited Requests
For expedited requests, you or the prescribing physician may call Customer Service at 541-768-4550 or 800-832-4580, from 8 a.m. to 8 p.m. daily. TTY users should call 800-735-2900.
Please note: If we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
To help us make a decision more quickly, you or your prescriber should include supporting medical information when you submit your request. If we approve your medication exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. For approval on prior authorizations please see our Prior Authorization Requirements. For further information regarding how to ask for an exception please refer to the Evidence of Coverage found with enrollment materials.
You may contact Medicare directly if you have any feedback or concerns, or if this is an urgent matter. Please call 800-MEDICARE (800-633-4227). TTY/TTD users can call 877-486-2048. Members can also download the Medicare Complaint Form.
As a new or continuing member in our plan, you may be taking drugs that are not on the formulary (drug list). You may also be taking a drug on our formulary that is restricted in some way. Under certain circumstances, you may be able to get a temporary supply.
How to Get a Temporary Supply
To be eligible for a temporary supply you must meet one of the changes listed below:
- Be a current member whose drug is no longer on the plan’s formulary drug list.
- Be a current member whose drug is now restricted in some way.
- Be a current member that has an unplanned change due to change in treatment settings. Examples include moving from a hospital to long-term care/skilled nursing or leaving a skilled nursing facility.
- Be a new member to the plan.
Long-Term Care Facility (LTC) Residents
For those members who reside in a long-term care (LTC) facility and were in the plan last year or are new to the plan:
We will cover a temporary supply of your drug during the first 90 days of the calendar year (current members) or during the first 90 days of your membership (new members). The total supply will be for a maximum of 91 days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 91 days of medication. Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.
For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility:
We will cover one 31-day supply or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
You Can Ask Your Doctor to:
- Switch you to a different drug that we cover, or
- Submit a formulary exception request for us to cover the drug you take.
Contact Us
To request a temporary supply, please call Samaritan Advantage at 800-832-4580 (TTY 800-735-2900), 8 a.m. to 8 p.m. daily.
A drug coverage redetermination is when you want us to reconsider and change a decision we have made about what drugs are covered for you or what we will pay for a drug. For example, if we deny the request for coverage determination and you think we should cover the medication, you can request a redetermination.
There are two kinds of coverage redeterminations you can request. They are described below.
Expedited Request
You can request an expedited (fast) coverage redetermination for cases that involve coverage, if you or your doctor believes that your health could be seriously harmed by waiting for a standard decision. For expedited requests, you or the prescribing physician may call Customer Service at 541-768-4550 or 800-832-4580, from 8 a.m. to 8 p.m. TTY users should call 800-735-2900. If your request to expedite is granted, the reviewer must give you a decision no later than 72 hours after receiving your request.
Standard Request
You can request a standard coverage redetermination for a case that involves coverage or payment for prescription services. You must file a request for coverage redetermination to Samaritan Advantage Health Plan HMO no later than 60 days from the date of the denial. The plan will review your request and make a determination as expeditiously as your health requires, but no later than 7 days from the date of the request.
Please include the following information:
- Name
- Address
- Member ID number
- The reasons for your request
- Any evidence you wish to attach
If your request relates to a decision by us to deny a drug that is not on our list of covered drugs (formulary), your prescribing physician must indicate that all the drugs on any tier of our formulary would not be as effective to treat your condition as the requested off-formulary drug or would harm your health. You or your appointed representative should mail your written request to the address below:
Samaritan Advantage Health Plan HMO
Attn: Part D Pharmacy Dept.
PO Box 1310
Corvallis, OR 97339
Drug Redetermination Request Form
Authorized Representative
As a member of Samaritan Advantage Health Plan HMO, you have appeal rights to adverse organization determinations for services requested. You also have the right to appoint any individual (such as a relative, advocate, friend, attorney or any physician) to act as your representative and file an appeal on your behalf.
By appointing a representative to act on your behalf concerning your appeal, you are giving him or her the right to:
- Obtain information about your claim to the extent consistent with Federal and State laws;
- Submit evidence;
- Make statements of fact and law; and
- Make any request, or give or receive any notice about the appeal proceedings.
To appoint a representative for your Medicare benefits, both you and the representative you’ve assigned must sign, date and complete Medicare’s authorized request form. You must send a copy to Samaritan Advantage Health Plan HMO each time you want the appointed representative to head any of your appeal requests within 60 days of the initial denial for the service requested. Once the form is received by Samaritan Advantage Health Plan HMO, it is considered current for one year. After one year has passed, you must complete a new form if you would like to continue the appointment of that representative.
If you are a member who takes many prescription drugs, or who has high drug costs or chronic diseases, you could be eligible for the Samaritan Advantage Health Plan HMO medication therapy management (MTM) program. This is a free service for eligible members.
Qualifications
To qualify for MTM, members must meet the following criteria:
- Must be taking a minimum of eight drugs covered by Medicare Part D
- Must have a prescription drug spend that is greater than or equal to $4,376 per calendar year
- Must have a minimum of three chronic diseases that Samaritan Advantage has chosen to monitor, as permitted by Centers for Medicare & Medicaid Services (CMS):
- Bone Disease-Arthritis-Osteoporosis
- Bone Disease-Arthritis-Rheumatoid Arthritis
- Chronic Heart Failure (CHF)
- Diabetes
- Dyslipidemia
- Hypertension
- Mental Health-Depression
- Respiratory Disease-Asthma
- Respiratory Disease-Chronic Obstructive Pulmonary Disease (COPD)
- HIV/AIDS
Program Details
Each eligible MTM member’s drug information is analyzed for potential drug-drug interactions, possible adverse effects of medications, or gaps in care. Every quarter, we automatically enroll qualified members in our MTM program so they may begin receiving this extra support. Eligible MTM members will receive a letter notifying them that they have been auto-enrolled into the MTM Program.
As an MTM member, you are also eligible to receive a comprehensive medication review. We will offer participation by mail and in some cases by phone. The comprehensive medication review will give you the opportunity to review all of your current medications with a pharmacist. This is a one-on-one conversation by phone that takes about 30 minutes.
After completing the review, you will be mailed a personal medication list and a medication action plan. The list will include your current prescription medications, over-the-counter medications and dietary and herbal supplements. The medication action plan will summarize what you and the pharmacist discussed during the medication review and discussion topics for you and your doctor. We will also conduct ongoing Targeted Medication Reviews and your doctor may be contacted by mail if we identify any issues with your medications.
Members who meet the MTM criteria are requested to participate in the program. Members are allowed to decline this service at any time during the contract year. During the contract year members may enroll into the MTM if they still meet the criteria.
The MTM is not a benefit, but a service provided by Samaritan Advantage. Members are encouraged to contact the plan’s Customer Service department at 800-832-4580 (toll free) or TTY 800-735-2900 daily from 8 a.m.to 8 p.m.
Samaritan Advantage is taking a multi-pronged approach to the nationwide opioid crisis. Beginning in 2019 our “opioid experienced” members will be limited to a 30-day supply and a cumulative morphine equivalent dose (MED) of 200 when filling opioid drugs. “Opioid experienced” is defined as filling an opioid claim in the last 120 days. Members who are “opioid naïve” (defined as not filling an opioid in the last 120 days) will be limited to filling no more than a 7-day supply. Members that reside in a long term care facility, in hospice care, are receiving palliative or end of life care, or are being treated for cancer-related pain are excluded from these safety edits.