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- 2021 Benefits Overview
2021 Benefits Overview
Review benefit information for Samaritan Choice members, including medical, prescription drug and pharmacy coverage information.
Your Medical Benefits
Review the table below for a quick look at coverage for the Choice Wellness Plan.
In-Network | Out-of-Network | |
---|---|---|
Deductible | $450/individual $1,350/family (Medical only) |
|
Out-of-Pocket Maximum |
$7,200/individual $14,400/family (Integrated Medical & Pharmacy) |
Unlimited/individual & family (Integrated Medical & Pharmacy) |
Doctor Office Visits (includes mental health) |
$25, deductible applies |
30%, deductible applies |
Specialist Visits | $40, deductible applies | 30%, deductible applies |
Urgent Care | $40, deductible applies | $40, deductible applies |
Emergency Care | $150, deductible applies | $150, deductible applies |
Chiropractic (Up to $850/year) |
$25, deductible applies |
30%, deductible applies |
Acupuncture | $35, deductible applies | 35%, deductible applies |
Telehealth | No charge, deductible does not apply | 30%, deductible applies |
For more detailed benefit information, review the plan documents.
Review the table below for a quick look at coverage for the HSA Eligible High-Deductible Plan.
In-Network | Out-of-Network | |
---|---|---|
Deductible | $2,800/individual $5,600/family (Integrated Medical & Pharmacy) |
|
Out-of-Pocket Maximum |
$5,000/individual $10,000/family (Integrated Medical & Pharmacy) |
Unlimited/individual Unlimited/family (Integrated Medical & Pharmacy) |
Doctor Office Visits |
$25, deductible applies |
30%, deductible applies |
Specialist Visits | $40, deductible applies | 30%, deductible applies |
Urgent Care | $40, deductible applies | $40, deductible applies |
Emergency Care | $150, deductible applies | $150, deductible applies |
Chiropractic (Up to $850/year) |
$25, deductible applies |
30%, deductible applies |
Acupuncture | $35, deductible applies | 35%, deductible applies |
Telehealth | No charge, deductible applies | 30%, deductible applies |
For more detailed benefit information, review the plan documents.
List of Covered Drugs & Pharmacies
Samaritan Choice Plans use a formulary — a list of drugs covered by the plan — to meet patient needs. The formulary does 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.
Network Pharmacies
This plan covers medically necessary prescription drug services through Samaritan Health Services pharmacies or any Walgreens pharmacy.
The following is a list of the current participating Samaritan Health Services pharmacies:
- Albany: Elm Street Pharmacy, 541-812-5071, 7 a.m. to 7 p.m., Monday–Friday, 9 a.m. to 5 p.m., Saturday, closed 1 to 2 p.m.; and Geary Street Pharmacy, 541-812-5544, 9 a.m. to 7 p.m., Monday–Friday, 9 a.m. to 5 p.m., Saturday, closed 1 to 2 p.m.
- Corvallis: Samaritan Pharmacy - Corvallis, 541-768-5225, 7 a.m. to 7 p.m., Monday–Friday, 9 a.m. to 5 p.m., Saturday, closed 1 to 2 p.m.
- Lebanon: Samaritan Pharmacy - Lebanon, 541-451-7119, 9 a.m. to 6 p.m., Monday–Friday (drive-up open until 7 p.m.), 9 a.m. to 5 p.m., Saturday (drive-up only), closed 1 to 2 p.m.
- Newport: Samaritan Pacific Communities Hospital - Pharmacy, 541-574-4740, 9 a.m. to 5 p.m., Monday–Friday, 9 a.m. to 3 p.m., weekends
- Lincoln City: Samaritan North Lincoln Hospital - Pharmacy, 541-996-7375, 9 a.m. to 4:30 p.m., Monday–Friday
Walgreens pharmacies are covered nationwide. You can reach their pharmacy department at 800-925-4733.
Review the pharmacy directory to see all our in-network pharmacies throughout the United States. Pharmacy Directory.
Samaritan Health Service Specialty Pharmacy can deliver your medication to your door, and we 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.
We also have a contracted specialty pharmacy, BriovaRX. Please contact them at 855-427-4682, if you need a specialty drug prescription filled.
When outside Linn, Benton, or Lincoln Counties, if there is not an in-network pharmacy in the area, members can call to request an override for emergent situations. For other situations members 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 Choice Claims Administrator for payment. Members will be reimbursed based on the Plan’s in-network contracted rate for prescription drugs minus member 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.
Your most cost effective option is to use generic drugs whenever available. Name brands are covered, but you most often will pay more for them. How much you pay depends on which tier a specific drug is categorized.
Forms
Prescription reimbursement claim: Request reimbursement for prescriptions obtained at a non-participating pharmacy.
Medication Exception: Request medication exception to Samaritan Choice Plans’ coverage rules, e.g., covering your drug even if it is not on the formulary, waiving coverage restrictions or limits on your drug, or providing a higher level of coverage for your drug.
Samaritan Choice Vision Plan
Summary of Benefits
This Plan pays for vision examinations, corrective lenses, and frames when prescribed by a licensed Ophthalmologist or licensed Optometrist for you and your insured dependents. The Plan allows you to choose any licensed Provider practicing within the scope of their license to provide vision benefits. However, for eye examinations, there is a difference in reimbursement for In-Network vision Providers and Out-of-Network vision Providers.
Please call Customer Service to verify the network status of your provider before obtaining services: 541-768-4550 or 800-832-4580 (TTY 800-735-2900).
In-Network Providers | Out-of-Network Providers | |
---|---|---|
Deductible | None | None |
Eye Examinations: One complete eye exam (including eye refraction exam) per calendar year | Covered 100% after a $25 copay | Covered 70% after a $25 copay |
Visual Acuity screening in children (ages0-21 years) |
Covered 100% | Covered 100% |
Vision Hardware and/or Accessories |
A combined benefit maximum limit of $300 per calendar year:
|
A combined benefit maximum limit of $300 per calendar year:
|
Limitations & Exclusions |
The following exclusions are not covered benefits under this Plan:
|
The following exclusions are not covered benefits under this Plan:
|
For more detailed benefit information, review the plan documents.
COBRA Continuation Coverage
The right to COBRA Continuation Coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA Continuation Coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage.
Choice Member Coverage Information
The plan documents describing your benefits can be found with your plan’s member benefits. These are the same documents referenced while you were a covered employee, spouse or dependent.
For more information, read the frequently asked questions below.
Member Forms
The COBRA Continuation Coverage forms are located on our Member Forms page.
COBRA Continuation of Coverage Frequently Asked Questions
Here are some questions that you might have about COBRA Continuation Coverage. Didn’t see your question? Send us an email.
The right to COBRA Continuation Coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA Continuation Coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to members of your family who are covered under the plan when they would otherwise lose their group health coverage.
COBRA Continuation Coverage is just what the name implies, simply a continuation of the coverage you had as an employee, spouse or covered dependent. The plan benefits are exactly the same as what you enjoyed as a regular covered member.
Qualifying events are specific situations that happen to a covered employee, spouse and/or dependent that result in a loss of group health coverage. Qualifying events include:
- Termination or reduction in hours of covered employee for reasons other than fraud
- Death of a covered employee
- A covered employee becoming entitled to Medicare
- Divorce or legal separation of a covered employee and spouse
- A child’s loss of dependent status under the plan
Qualifying events occur while the employee/covered dependents are still receiving group health coverage. Second qualifying events occur after the employee/qualified beneficiaries are receiving COBRA Continuation Coverage.
It is the responsibility of the employee, spouse and/or dependent to report a divorce, legal separation and a child’s loss of dependent status to your local Samaritan Health Services Human Resources Department within their required time frame. If these events occur while on COBRA Continuation Coverage, report them to Samaritan Health Plans within a 60-day time frame. Termination/reduction in hours, death, or entitlement to Medicare must be reported to the plan administrator by the employer within 30 days of the event.
Fill out the COBRA Continuation Coverage Election Form and mail or hand-deliver it to Samaritan Health Plans within the required timeline. Follow the specific instructions on the form. This form should be used for all qualified beneficiaries electing COBRA Continuation Coverage.
Mail to:
Samaritan Health Plans
PO Box M
Corvallis, OR 97339
Hand-deliver to:
Samaritan Health Plans
2300 NW Walnut Blvd.
Corvallis, OR 97330
The type of qualifying event determines who the qualified beneficiaries are for that event and the period of time the plan must offer continuation coverage. The chart below helps explain who qualifies for what length of coverage by qualifying event:
Maximum coverage period | Qualified beneficiaries (Only members covered by the plan the day before the event occurred or a child born to or placed for adoption with a covered employee during continuation coverage) |
|
---|---|---|
Covered employee’s termination of employment | 18 months | Employee, spouse, dependents |
Covered employee’s reduction in work hours (for any reason) below those required to maintain normal coverage | 18 months | Employee, spouse, dependents |
Covered employee’s divorce or legal separation | 36 months | Spouse, dependents |
Covered employee’s death |
36 months | Spouse, dependents |
Covered employee’s entitlement to Medicare benefits | Up to 36 months | Spouse, dependents |
Loss of status as a dependent child of the covered employee under the Plan rules | 36 months |
Dependents |
Early termination of COBRA Continuation Coverage can be the result of any of the following:
- The employer no longer provides any group health coverage for its employees.
- The required initial premium payment was not made in full within 45 days after the election date.
- A monthly premium payment was not made within the 30-day grace period.
- The member became covered under another group health plan or Medicare entitled and after review they were no longer eligible for COBRA coverage.
- A 29-month maximum coverage period ended early due to Social Security Administration determining there was no longer a disability.
- You requested your COBRA coverage be terminated.
- While on COBRA coverage, an event occurred that would be cause for termination of coverage for a person not receiving COBRA coverage (such as fraud).
This general notice explains the rights of covered individuals to elect group health continuation coverage at the time they experience certain events that result in a loss of coverage. It’s important to understand this notice as it outlines the employee’s responsibility to report certain events.
Human Resources will report a qualifying event to Samaritan Health Plans (SHP). Within 14 days of receiving that notification, SHP will send an Election Notice packet to the employee, spouse, and/or dependents that will include a COBRA Continuation Coverage Election Notice. This notice gives specifics about how to elect COBRA Continuation Coverage.
In addition to the COBRA Continuation Coverage Election Notice, this election packet also contains:
- COBRA Continuation Coverage Election Form
- COBRA Address Notification Form
- COBRA Premium Rate Sheet
- Flexible Spending Account Continuation Coverage Election Notice (only for members who have an underspent flexible spending account at the time of the qualifying event)
When a qualified beneficiary reports certain second qualifying events during COBRA Continuation Coverage, an Election Notice packet will also be sent.
All COBRA Continuation Coverage forms needed by qualified beneficiaries can be found on the Member Forms page. The three forms available to qualified beneficiaries include:
COBRA Continuation Coverage Election Form: used by members to enroll in COBRA Continuation Coverage
COBRA Address Notification Form: used by members to provide Samaritan Health Plans current mailing addresses for all COBRA Continuation Coverage members
COBRA Qualifying Event or Extension Notification form: used by members to report specific events
There may be other coverage options for you and your family:
- You may be able to buy coverage through the Health Insurance Marketplace. In the Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums right away, and you can see what your premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll. Being eligible for COBRA does not limit your eligibility for coverage for a tax credit through the Marketplace. For more information about health insurance options available through the Health Insurance Marketplace, visit www.healthcare.gov
- You may also want to contact your state to ask if there is a premium payment program that may assist you with the payment of your premiums. Contact your local Department of Human Services office for information.
- Additionally, you may qualify for a special enrollment opportunity for another group health plan for which you are eligible (such as a spouse’s plan), even if the plan generally does not accept late enrollees, if you request enrollment within 30 days.
Your initial premium payment is due within 45 days of the date you elect COBRA Continuation Coverage. You may make your initial payment at the time you submit your election form, or you may wait to make it after you elect, but before the 45-day deadline. If you send in your initial payment with your election notice, the examples below will help you figure out the amount of your initial payment:
- If you elect COBRA coverage between the first and 30th day after your loss of coverage, your initial premium payment is one month of COBRA coverage. Your next payment is due on the first day of the following month. For example, if your loss of coverage date is April 30, and you elect coverage May 27, your initial payment should cover the month of May. Your next payment will be due June 1 and must be paid within the 30-day grace period.
- If you elect COBRA coverage between the 31st and 60th day of your original loss of coverage, your initial premium payment is two months of COBRA coverage (unless you are only electing one month of coverage). Your next payment is due on the first day of the following month. For example, if your loss of coverage date is April 30, and you elect coverage June 18, your initial payment should cover both May and June. Your next payment will be due July 1 and must be paid within the 30-day grace period.
If you do not send your initial payment with your election notice, but pay within the 45 days after you elect, your initial premium payment and any subsequent monthly premiums will be due. The following example assumes your loss of coverage date is April 30 and you elect coverage June 29. If you send in your payment on August 8 (40 days after your election date), at a minimum, your payment should cover the months of May, June, and July. And, your August payment (due August 1) must be paid within the 30-day grace period, by August 31.
If you have questions about the amount of your initial premium payment, call Samaritan Health Plans Customer Service. You can reach them Monday through Friday, from 8 a.m. to 8 p.m. by calling 541-768-4550, 800-832-4580, or TTY 800-735-2900, or in person Monday through Friday, from 8 a.m. to 5 p.m. at Samaritan Health Plans, 2300 NW Walnut Blvd., Corvallis, OR 97330.
Your premiums can be paid by cash, check, money order or credit card payments. You may either mail or hand-deliver your payment using the addresses below:
Mail to:
Samaritan Health Plans
PO Box M
Corvallis, OR 97339
Hand-deliver to:
Samaritan Health Plans
2300 NW Walnut Blvd.
Corvallis, OR 97330
The following chart displays very important deadlines that you must meet to avoid losing your COBRA Continuation Coverage rights:
Timeline to Report | |
---|---|
Report the following Second Qualifying Events To Samaritan Health Plans (SHP):
|
Within 60 days of the later of:
|
Once you receive the COBRA Coverage Election Notice, if you choose to elect, you must submit a completed COBRA Coverage Election Form to SHP. |
Within 60 days of the later of:
|
If you elect COBRA Continuation Coverage, you must mail or hand-deliver your initial payment to SHP (if you did not send your initial payment with the COBRA Coverage Election Form). |
Within 45 days of the date you elect COBRA Continuation Coverage |
Your monthly premium payments are due on the first of each month. You must mail or hand-deliver your monthly premium payments to SHP. Qualified beneficiaries may request special enrollment. (For example, in a spouse’s health plan). | By the end of the 30-day grace period It must be within 30 days of the loss of other coverage (including at the end of the COBRA Continuation Coverage maximum period). |
Disability—If you are reporting the disability of a qualified beneficiary, you must send SHP a copy of the Social Security Administration ruling letter. | Within 60 days and before the end of the original 18-month period of COBRA coverage. 60 days from the later of:
|
No longer disabled-You must report to SHP a Social Security Administration determination that the disabled qualified beneficiary is no longer disabled. |
Within 60 days after the Social Security Administration determination was made |
Yes, disability and second qualifying events.
1. A disability determination for any of the qualified beneficiaries in a family can extend the original 18-month period of continuation coverage an additional 11 months (29 months total). To qualify for a disability extension, the qualified beneficiary must:
- Receive a ruling from the Social Security Administration that he or she became disabled before the 60th day of COBRA Continuation Coverage, and
- Send Samaritan Health Plans a copy of the Social Security ruling letter within 60 days and before the end of the original 18-month period of COBRA coverage. The 60 days begins from the latest of the following:
- The date Social Security Administration issues the disability determination
- The date of the qualifying event
- The date of loss of coverage
- The date the qualified beneficiary is informed of the responsibility to notify the COBRA administrator
If these requirements are met, all the covered qualified beneficiaries qualify for an additional 11 months of COBRA Continuation Coverage, as long as the person remains disabled through the entire original 18-month benefit period.
2. Second events can only be considered qualifying events if they would have caused the loss of coverage if the first event had not happened. They can extend the original 18-month benefit period an additional 18 months (36 months total) only for a spouse, ex-spouse or dependent. Second qualifying events include:
- Death of the covered employee
- Divorce or legal separation of the covered employee and spouse
- Medicare entitlement
- Loss of dependent child status under the plan
Members on COBRA Continuation Coverage should use the COBRA Qualifying Event or Extension Notification form located under the Member Forms tab of the Samaritan Choice Benefits page to report the following events:
- Divorce/Legal Separation
- Child Ceasing to Be an Eligible Dependent under the Plan
- Death of Employee
- Covered Employee Entitled to Medicare
- Adding New Dependents
- Social Security Disability
- Ceasing to be Social Security Disabled
- Other Coverage or Medicare Entitlement
Talk with our Member Services representatives
Mon.–Fri.