Links to other sites:

Centers for Medicare and Medicaid Services (CMS): www.cms.hhs.gov Medicare www.medicare.gov Samaritan Health Services (SHS): www.samhealth.org Social Security Administration (SSA): www.ssa.gov
Member Rights

To request a non-formulary medication or obtain a medication prior authorization

Coverage Determination/Medication Exception
You can ask us to make a medication exception to our coverage rules if you are a member of one of our plans that  offer prescription drug coverage: the Samaritan Advantage Premier Plan or the Samaritan Advantage Special Needs Plan. This includes exceptions for:

  • Covering your drug even if it is not on our formulary.
  • Waiving coverage restrictions or limits on your drug.
  • Providing a higher level of coverage for your drug.

     SAHP500.pdf (87k) Coverage Determination/Medication Exception Form

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. In order to help us make a decision more quickly, you should include supporting medical information from your doctor when you submit your medication exception 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.  If we deny your medication exception request, you can appeal our decision. Back to top.

Drug Management Programs
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 also 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.  If they don't get approval, we may not cover the drug.

     SAHP500.pdf (87k) Prior Authorization Form
  • 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, we will provide up to 12 doses per prescription for Zomig. 
  • 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.
  • Generic Substitution: When there is a generic version of a brand-name drugs available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug. 

You can find out if your drug is subject to these additional requirements or limits by looking in the formulary.  If your drug does have these additional restrictions or limits, you can ask us to make an exception to our coverage rules.  For further information regarding how to ask for an exception please refer to your Evidence of Coverage in Section VI under section, "How do I request an exception to the formulary?"  Back to top.

Filing a complaint with Samaritan Advantage Health Plan

As a member of Samaritan Advantage Health Plan you have the right to make a complaint if you have concerns or problems related to your coverage or care. There are two different types of complaints that you can make:  a grievance or an appeal.

Grievance
A “grievance” is the type of complaint you make if you have any type of problem with Samaritan Advantage Health Plan or one  of our plan providers. You would file a grievance if you have a problem with, for example, the quality of your care, waiting times for appointments or time spent in the waiting room, the way your doctors, pharmacists or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor’s office or pharmacy. If you have a grievance, we encourage you to first call Member Services at the numbers located at the end of this document.

Expedited Grievance
If you receive a denial for an expedited appeal request and disagree with the decision made by Samaritan Advantage Health Plan, you may request an expedited grievance. By requesting an expedited grievance you are asking us to review your case again for an expedited timeframe, and we must resolve and inform you of the decision within 24 hours. You may request an expedited grievance either verbally or in writing by contacting Member Services at the numbers located at the end of this document.

You will be notified verbally within 24 hours from the receipt of your expedited grievance and will receive written notice within 72 hours if it was denied.  We will try to resolve any grievance that you might have over the phone. If you request a written response to your phone grievance, we will respond in writing to you. If we cannot resolve your grievance over the phone, we have a formal procedure to review your grievance.

Depending on the nature of the complaint, your grievance is forwarded to an Operations Manager who is responsible  for investigating and resolving the matter. We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your grievance. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. 

For quality of care problems, you may  also file a grievance to OMPRO. OMPRO  is the quality improvement organization that oversees our plan decisions.

If you are concerned about the quality of care you received, including care during a hospital stay, you can file a grievance directly to OMPR

OMPRO
2020 SW Fourth Avenue, Suite 520 
Portland, OR 97201
503-279-0100 or toll free: 800-344-4354
Fax: 503-279-0190   

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Appeal
An “appeal” is the type of complaint you make when you want us to reconsider and change a decision we have made about what services or benefits are covered for you or what we will pay for a service or benefit. For example, if we refuse to cover or pay for services you think we should cover, you can file an appeal. If Samaritan Advantage Health Plan or one of our plan providers refuses to give you a service  you think should be covered, you can file an appeal. If Samaritan Advantage Health Plan or one of our plan providers reduces or cuts back on services or benefits you have been receiving, you can file an appeal.

If you think we are stopping your coverage  of a service or benefit too soon, you can file an appeal. If you think that we should have covered a prescription that was denied through the medical exception process, you can file an appeal. Please see the information that follows for instructions on how to file an appeal.

There are two kinds of appeals you can request:

  • Expedited Requests—You can request  an expedited (fast) appeal for cases that involve coverage, if you or your doctor believes that your health could be seriously harmed by waiting for a standard decision. If your request to expedite is granted, the reviewer must give you a decision no later than 72 hours after receiving your appeal.
  • Standard Requests—You can request  a standard appeal for a case that involves coverage or payment for medical or prescription services. The reviewer  must give you a decision within specific timeframes as described below, depending on whether the request is for medical or prescription services.

Timeframes for a request regarding your MEDICAL BENEFITS:

You must file your request for appeal to Samaritan Advantage Health Plan no later than 60 days after receiving the denial for your services. Samaritan Advantage Health Plan will review your appeal request and make a determination as expeditiously as your health requires, but no later than 30 days from the date of the appeal request.

Timeframes for a request regarding your PRESCRIPTION BENEFITS:

You must file a request for appeal to Samaritan Advantage Health Plan no later than 60 days from the date of the denial. Samaritan Advantage Health Plan will review your appeal request and make a determination as expeditiously as your health requires, but no later than 7 days from the date of the request.

What do I include with my appeal?
You should include your name, address, Member Id number, the reasons for appealing, and any evidence you wish to attach. If your appeal 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.

How do I request an appeal?
You or your appointed representative should mail your written appeal request  to the address below:

Samaritan Advantage Health Plan
P.O. Box M
Corvallis, OR 97339

If your appeal request is for a prescription drug, please address to “Part D Appeals”  and send to the address above.

What happens next?
After reviewing your appeal, we will decide whether to stay with our original decision, or change this decision and give you some or all of the care or payment you want. If we turn down part or all of your request  for a medical service, we are required to send your request to an independent review organization that has a contract with the federal government and is not part of Samaritan Advantage Health Plan. This organization will review your request and make a decision about whether we must give you the care or payment you want. If we turn down part or all of your request  for a prescription, you may request an independent review organization, Center for Health dispute Resolution (CHdR), review your appeal.

For more information about your appeal rights, call us or see your Evidence of Coverage.
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Authorized Representative
As a member of Samaritan Advantage Health Plan 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 both you and the representative you’ve assigned must sign, date and complete an Authorized Representative Form. Once the form is received by Samaritan Advantage Health Plan it is considered current for one year. You must send a copy to Samaritan Advantage Health Plan 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. After one year has passed, you must complete a new form if you would like to continue the appointment of that representative.

 cms1696.pdf (67k) Authorized Representative Form

IMPORTANT INFORMATION  ABOUT YOUR APPEAL RIGHTS

For more information about your appeal rights, call us or see your Evidence of Coverage.

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Contact Information 

If you need information or help regarding a MEDICAL COMPLAINT, call or fax us at:

(541) 768-4550
Toll Free: 1-800-317-7489
TTY: 1-800-735-2900
Fax: (541) 768-4294

If you need information or help regarding a PRESCRIPTION COMPLAINT, call or fax us at:

(541) 768-5207
Toll Free: 1-800-435-2396
TTY: 1-800-735-2900
Fax: (541) 768-4294

Other resources to help you:

Medicare Rights Center 
Toll Free: 1-888-HMO-9050 
TTY: 1-800-735-2900

Elder Care Locator 
Toll Free: 1-800-677-1116 
1-800-MEDICARE (1-800-633-4227) 
TTY: 1-877-486-2048

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Contact Us | Patient Privacy Policy | Terms of Use
Beneficiaries of Samaritan Advantage Health Plan must have Medicare Part A and Part B and must continue to pay Medicare premiums.
Enrolled beneficiaries must use Samaritan Advantage health Plan contracted providers for routine care.
Samaritan Advantage Health Plan is an HMO with a Medicare Advantage Contract.