Select an insurance plan below to see what drugs are covered by that plan.
A formulary is a list of covered drugs selected by our 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.
A committee of physicians and pharmacists reviews scientific evidence to determine which medications should be included in Samaritan Health Plans formularies.
Our pharmacy directories list all network pharmacies. You can go to any network pharmacies to use your prescription drug benefit. You are not required to continue using the same network pharmacy to fill your prescriptions.
For the 2025 directory, pharmacies that are part of our “preferred network” are indicated with (PREFERRED) next to their name. By using a preferred pharmacy, you will pay a lower copay than if you use a standard network pharmacy.
Use your prepaid benefits MasterCard to pay for eligible over-the-counter expenses. See eligible OTC items:
A formulary is a list of drugs covered by your plan. You can search for a medication on a formulary by name or type. Search results include:
You can use our online search tool:
You may also download and print the formularies (or print specific pages):
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 Dual Advantage Plan. 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, also known as CMS, requirements for pharmacy access in your area. In most cases, your prescriptions are covered if they are filled at a network pharmacy.
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.
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.
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:
Before you fill your prescription in any of these situations, call Customer Service at 541-768-7866 or 866-207-3182 (TTY 800-735-2900), from 8 a.m. to 8 p.m. daily, to see if there is a network pharmacy in your area where you can fill your prescription.
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. 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:
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.
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.
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 Plans 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 seven days from the date of the request.
Please include the following information:
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 Plans HMOAttn: Appeals Dept.PO Box 1310Corvallis, OR 97339
As a member of Samaritan Advantage Health Plans 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:
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 Plans 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 Plans 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.
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:
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.
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.
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.
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, also known as 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.
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.
To be eligible for a temporary supply you must meet one of the changes listed below:
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.
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.
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 adjusted amount you will pay. See the table below for the monthly premiums for the current year.
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 socialsecurity.gov.
The following chart outlines the adjusted premium amounts for 2024 based on the various low-income subsidy levels.
For generic/preferred multi-sourced drugs, you pay either a $0, $1.55 or $4.50 copay per prescription. For all other drugs, you pay either a $0, $4.60 or $11.20 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.
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 2024 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:
You, your representative, or your prescriber can submit a medication exception / prior authorization if:
To request an exception, you, your authorized representative, or the prescribing physician have the following options:
Samaritan Advantage Health Plan HMOPO Box 1310Corvallis, OR 97339
844-403-1028
Samaritan Health Plans2300 NW Walnut Blvd., CorvallisMonday through Friday, 8 a.m. to 5 p.m.
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 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.
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 2024 Pharmacy Directory.
You can order your prescriptions for rapid mail delivery from Samaritan Health Services:
Samaritan Pharmacy – Corvallis3251 NW Samaritan Drive, Suite 202, CorvallisPhone: 541-768-5225Refill line: 541-768-5230
If you are a Samaritan Advantage 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 Program, also known as MTM. This is a free service for eligible members. Learn more.
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, or 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.
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.
A change in the law requires companies that make brand-name prescription drugs to give a discount on those drugs to Medicare. Beginning Jan. 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 medicare.gov.
Subscriber(s) must use a network pharmacy for prescription drug benefits. If there is not an in-network pharmacy in the area, subscriber(s) may call to request an override for emergent situations. For other situations subscriber(s) may pay out-of-pocket for the full cost of the drug then submit for reimbursement. Please submit a Prescription Reimbursement form with receipt to the claims administrator for payment. Subscriber(s) will be reimbursed based on the plan’s in-network contracted rate for prescription drugs minus subscriber(s) co-pay or co-insurance. Note: the cash price paid at the pharmacy is generally higher than the plan’s in-network contracted rate for prescription drugs.
Pharmacy Directory – IHN-CCO (updated 10/5/2024).
A formulary is a list of drugs covered by your plan. You can search for a medication by name or type. Search results include:
You can search the online formulary for IHN-CCO members or for IHN-CCO Dual Eligible* members:
You may also download and print the formulary (or print specific pages):
*Dual-eligible refers to members who qualify for both Medicare and Medicaid benefits. For dual eligible members, IHN-CCO (Medicaid) covers formulary over-the-counter medicine (drugs). All other medicine prescribed by your provider will be billed to your Medicare plan.
Occasionally formulary coverage can change during the year. See a list of updates for specific medications on the IHN-CCO Formulary.
We require you to get prior authorization for certain drugs. This means that your provider will need to get approval from us before you fill your prescription. Without approval, we may not cover the drug.
EPSDT is a comprehensive child and youth health care benefit for OHP members ages birth to 21 (EPSDT coverage ends when a person turns 21). This includes physical, dental, behavioral health and pharmacy services. Beginning Jan. 1 2023, IHN-CCO will cover any medically necessary and medically appropriate services for members enrolled until their 21st birthday, regardless of the location of the diagnosis on the Prioritized list of Health Services.
A network pharmacy is one that we have made arrangements for them to provide prescription drugs to plan members. Check the pharmacy directory below for both small and large group plans to see all in-network pharmacies throughout the United States. You may also search the online 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.
Pharmacy Directory – Small & Large Group Plans (updated 10/5/2024).
A formulary is a list of drugs covered by your plan. You can search for a medication on a formulary by name or type. The formularies do not contain the names of all medications available in the market. Search results include:
If a medication is not listed, please contact Customer Service for assistance: 800-832-4580 (TTY 800-735-2900), from 8 a.m. to 8 p.m., Monday through Friday.
You can use an online search tool:
Employee/subscriber(s) must use a network pharmacy for prescription drug benefits. Check the pharmacy directories below to see all in-network pharmacies throughout the United States.
Samaritan Health Service Specialty Pharmacy can deliver your medication to your door and will partner with your health care team to manage your refills and monitor your lab work to make sure the medications are keeping you on the right path. Please contact them at 541-768-1299, weekdays, 8 a.m. to 4:30 p.m.
Employee/subscriber(s) must use a network pharmacy for prescription drug benefits. If there is not an in-network pharmacy in the area, employee/subscriber(s) may call to request an override for emergent situations. For other situations employee/subscriber(s) may pay out-of-pocket for the full cost of the drug then submit for reimbursement. Please submit a Prescription Reimbursement form with receipt to the Choice claims administrator for payment. Employee/subscriber(s) will be reimbursed based on the plan’s in-network contracted rate for prescription drugs minus employee/subscriber(s) co-pay or co-insurance. Note: the cash price paid at the pharmacy is generally higher than the plan’s in-network contracted rate for prescription drugs.
You can also download a comprehensive machine readable format(MRF) of plan formularies. More MRFs for each plan will be available as we receive them.
Provider Administered Drugs are medications given by a provider in their office. These are not a pharmacy benefit.
Prior Authorization List – Provider Administered Drugs – IHN-CCO Prior Authorization Criteria – Provider Administered Drugs – IHN-CCO
Prior Authorization List – Provider Administered Drugs – Employer Small & Large GroupPrior Authorization Criteria – Provider Administered Drugs – Employer Large GroupPrior Authorization Criteria -Provider Administered Drugs – Employer Small Group
Prior Authorization List – Provider Administered Drugs – Samaritan ChoicePrior Authorization Criteria – Provider Administered Drugs – Samaritan Choice
Prior Authorization List – Provider Administered Drugs – Samaritan AdvantagePrior Authorization Criteria – Provider Administered Drugs – Samaritan Advantage
Outpatient provider-administered specialty and oncology drug authorizations are submitted through the Specialty Fusion portal.
Select medications may require prior authorization. A physician may submit authorization requests by:
You can call Customer Service for additional questions at 541-768-5207 or toll free at 888-435-2396.
Page Updated 6-17-2024
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