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Download the important plan information you need here. Still have questions? Contact us!

Summary of Benefits

2022 Summary of Benefits - Conventional, Premier and Premier Plus

Prescription Drugs

2022 Premier Plan and Premier Plan Plus Formulary (effective 1/1/2022)
2022 Special Needs Plan Formulary (effective 1/1/2022)
2022 Pharmacy Directory

Enrollment Form

2022 Samaritan Advantage Enrollment Form
Enrollment Instructions
Pre-enrollment Checklist
Low-Income Subsidy Premium Summary

Helpful Information

2022 Prior Authorization List
Multi-language interpreter services
Plan Star Ratings*

Evidence of Coverage

2022 Evidence of Coverage - Conventional Plan
2022 Evidence of Coverage - Premier Plan
2022 Evidence of Coverage - Premier Plan Plus
2022 Evidence of Coverage - Special Needs Plan  

Looking for a copy of our provider directory? You can find it on our Provider Directory Search page.

*Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.

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Page updated 10/01/2021