WHAT'S NEW
MAY I HELP YOU?
We invite you to call or visit us today: Samaritan Health Plans, 815 NW 9th Street,
Corvallis OR 97330, M-F, 8a.m. to 5 p.m.
(541) 768-6900
(800) 569-4616
Benefits at a glance
Check out WHAT’S BEEN ADDED FOR 2008! >
| 2008 SUMMARY OF BENEFITS | Print version | |
| Preferred Providers | Non-Preferred Providers | |
| Annual Out-of-Pocket Maximum | $1,000/person; $3,000/family |
$2,000/person; $6,000/family |
| Individual Lifetime Maximum | $2 million | |
| Type of Providers | Samaritan Network Preferred Providers | Any Licensed Provider |
| MEDICAL SERVICES | You Pay Preferred | You Pay Non-Preferred |
| Office Visit | ||
| Primary Care office visit | $10 | 30% |
| Specialist office visit | $10 | 30% |
| X-ray & Lab | $0 | 30% |
| Preventive Care | ||
| Periodic health appraisals | $0 1, 2 | 30% 1, 2 |
| Well-child check up (to age 19) |
$0 1 | 30% 1 |
| Hearing screenings | $0 | 30% |
| Routine immunizations | $0 | $0 |
| Mammography screening | $0 1 | 30% 1 |
| Routine women’s exam | $0 1 | 30% 1 |
| Bone density screening | $0 3 | 30% 3 |
| Colonoscopy screening | $0 1 | 30% 1 |
| Prostate screening | $0 1 | 30% 1 |
| Diabetes and asthma care | $0 | 30% |
| Hearing | ||
| Hearing exam | $10 4 | 30%4 |
| Hearing aids, up to $4000 (every 4 years) | 10%4 | 10%4 |
| Hospital | ||
| Ambulance | $75 3, 5 | $75 3, 5 |
| Inpatient, unlimited days | $100/day, $500/year | 30% |
| Outpatient | $10 | 30% |
| Emergency room | $75 3, 5 | $75 3, 5 |
| Maternity & Gynecology | ||
| Prenatal and postpartum office visits | $10 | 30% |
| Inpatient delivery | $100/day, $500/year | 30% |
| Infertility treatment | 50% 6 | 50% 6 |
| Surgery | ||
| Inpatient | $0 7 | 30% 7 |
| Outpatient | $10 7 | 30% 7 |
| Office-based | $10 7 | 30% 7 |
| Mental Health & Chemical Dependency | ||
| Inpatient & Residential | $100/day, $500/year6, 7 | 30% 6, 7 |
| Outpatient | $10 6, 7 | 30% 6, 7 |
| Durable Medical Equipment | 15% | 30% |
| Insulin, diabetic supplies | $0 | $0 |
| Alternative Care | $15 8 | $15 8 |
| Misc. Services | ||
| Outpatient Rehab | 15% | 30% |
| Injectibles and therapeutic injectibles | 15% | 30% |
| Cardiac Rehab | 15% | 30% |
| Home Health | 15% | 30% |
| Skilled nursing facility | 15% | 30% |
1. Based on plan’s frequency schedule.
2. Includes commercial driver’s license medical exam for employee.
3. When medically appropriate.
4. Hearing aids covered at $4000 every 4 years.
5. Based on criteria including prudent layperson law.
6. Some diagnoses and treatments may not be covered benefits.
7. Some services may require prior authorization.
8. Includes chiropractic, naturopathic and acupuncture services. Limited to $1,000 per year.
| PRESCRIPTION DRUGS | Participating Pharmacies Only |
| Retail | 34-day supply |
| Therapeutic | $0 |
| Generic | $5 |
| Brand | $15 |
| Non-preferred Brand | >$50 or 50%* |
| Mail Order | 90-day supply |
| Therapeutic | $0 |
| Generic | $12.50 |
| Brand | $37.50 |
| Non-preferred Brand | >$125 or 50%* |
* Plus the difference between generic and brand for multisource brands. Multisource brand is a brand where there is an exact generic
equivalent available.
| Vision Services | Routine vision care covered through VSP |
