Welcome to Summit Health
The resources you need to manage your plan and benefits.
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Find a Provider
File a claim
Formulary
Prior authorization
Prescription drug coverage determination
Plan materials
Appeals and grievances
Star ratings
Enrollment forms
Search for in-network providers, facilities, and pharmacies using our online Find Care directory.
Find CareBeginning January 1, 2025, Summit Health will no longer be offering Medicare Advantage plans in the state of Oregon.
Download a PDF/printable version of our Eastern Oregon directories. Counties include Baker, Gilliam, Grant, Harney, Lake, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, and Wheeler.
For help with a printed directory, email medicalmedicare@yoursummithealth.com.
If you get a medical or a prescription filled at an out-of-network service area for one of the reasons below, you can request that we reimburse you. We make decisions about reimbursement based on your Evidence of Coverage.
Circumstances for out-of-network prescription coverage:
To submit a claim, please complete our medical paper claim form (English), medical paper claim form (Spanish), pharmacy paper claim form (English) pharmacy paper claim form (En Español). Mail it and your prescription receipt to the address on the form. You will need to submit this claim within 60 days of getting your out-of-network prescription filled.
If you need help filing a claim, please call our Summit Health Customer Service at 844-827-2355 (TTY users, please call 711). Customer Service is available to help you from 7 a.m. to 8 p.m., Pacific Time, seven days a week from Oct. 1 to March 31. After March 31, your call will be handled by our automated phone system on weekends and holidays. Weekend calls are forwarded to voicemail and returned the next business day.
Our formulary is our list of covered generic and brand-name prescription drugs for plans that have prescription drug coverage.
To view the formulary you can:
If you do not see the drug you are looking for in the formulary, please call our pharmacy customer service. We may cover that drug.
If you’re a current Summit Medicare Advantage member, please access the online benefit tool for prescription drugs through your Summit Member Dashboard for a more accurate cost estimate that accounts for your personal claims.
*Prescription drug information displayed on the online benefit tool is subject to change without notice and is not a guarantee of benefits. Your coverage is based on your plan benefit and eligibility at the time of service. If you have copay assistance it may affect your deductible and/or your maximum out of pocket amount. Coverage and cost sharing may vary for preventive service.
To request prior authorization, you or your provider can call Summit Health Customer Service at 844-931-1778. They can also fax our prior authorization request form (English) | prior authorization request form (En Español) to 855-637-2666.
When we say you need to get prior authorization for a service or prescription drug, it means that you need to get pre-approval from us to cover it. Prior authorization is also referred to as organization determination or coverage determination. Prior authorization is required for:
To request a prescription drug coverage determination, redetermination, or prior authorization, see coverage determination below.
Coverage determination is a decision about whether or not a prescription drug is covered. The determination also lets you know how much we cover and how much you need to pay. If a pharmacy says your prescription is not covered, that is not coverage determination. We make that decision. Please call or write us with questions: Please call our Summit Health Customer Service at 844-827-2355. TTY users, dial 711. Customer Service is available to help you from 7 a.m. to 8 p.m., Pacific Time, seven days a week from Oct. 1 to March 31. After March 31, your call will be handled by our automated phone system on weekends and holidays. Weekend calls are forwarded to voicemail and returned the next day.
If you would like to request coverage determination, you or your provider may do one of the following:
A redetermination request is an appeal of a denied coverage determination. If you would like to request coverage redetermination, you or your provider may do one of the following:
You can assign someone you trust to help you manage your Medicare plan. This is what we mean when we say, “appoint a representative.” You can choose whomever you like. It could be a relative, friend, advocate, doctor, etc. To do this, please complete our Appointment of Representative form | Appointment of Representative form ESP. You will need to have the person you appoint sign the form. Then, this person can request coverage determination, redetermination and/or file a grievance for you.
Use your Evidence of Coverage to find out what is covered in your plan and how your plan works. All of the details about your plan are included in the EOC.
Your Summary of Benefits includes highlights of your plan such as your monthly premium, annual out-of-pocket maximum, and copays for medical services.
Each fall, we will send you an Annual Notice of Changes. Review the Annual Notice of Changes to see any changes in costs, coverage and service area. These changes will take place in January.
If you have concerns or problems with any part of your benefits, care, service or prescription drugs; you can file a complaint. Appeals and grievances are the two types of complaints you can file. Learn more about filing an appeal or grievance in your Evidence of coverage.
If you do not agree with a decision we have made, you can make an appeal (a request to change the decision) within 60 days. You can do this for decisions about services and payment. You can also request that we cover an item or service that is not in your plan. If you need to ask for a review of a medical care coverage decision made by our plan, you or your provider may do one of the following:
844-827-2355
833-949-1888
Summit Health
Attn: Medicare Appeal and Grievance
P.O. Box 820070
Portland, OR 97282
Complete our online Prescription drug redetermination request form
If you prefer to mail or fax your request, you may complete this prescription drug redetermination request form.
If your health requires a quick response, you must ask for a “fast appeal.” You or your provider may do one of the following:
833-460-0451 (voicemail only) and leave a message with your name, plan ID and details of your request.
Submit a written request and fax to 833-949-1888,
Attn: Medicare Expedited Appeal and Grievance
Summit a written request and mail to:
Summit Health
Attn: Medicare Appeal and Grievance
P.O. Box 820070
Portland, OR 97282
Please make sure to write “expedited appeal” on your request.
If you are not satisfied with us or one of our providers, you can file a grievance. A grievance is not for coverage or payment. Learn move about filing a grievance in your Evidence of Coverage.
To submit your grievance, you can call us or mail your grievance to:
Summit Health
Attn: Summit Health Medicare Appeals
P.O. Box 820070
Portland, OR 97282
You can assign someone you trust to request authorization, or file a claim, grievance or appeal. To do this, please complete our Appointment of Representative form | Appointment of Representative form ESP. You will need to have the person you appoint sign the form. You can submit this form with your appeal or grievance request.
We work to resolve any issues you may have. You can also file a complaint directly with the Centers for Medicare & Medicaid Services (CMS) by using their online complaint form.
The Centers for Medicare and Medicaid Services (CMS) Medicare Star Ratings system was made to help you compare options when choosing a health and drug plan. Each year, CMS evaluates Medicare Advantage and Part D plans and assigns Star Ratings based on a 5-star rating system.
The following ratings tell you the quality of the medical and prescription drug services, customer service, member experience and overall quality of the plan.
5-Star = Excellent
4-Star = Above average
3-Star = Average
2-Star = Below average
1-Star = Poor
2024 Medicare Advantage Star Rating for Summit Health
2024 Medicare Advantage Star Rating for Summit Health (En Español)
Summit Health Enrollment (English)
Summit Health Enrollment (En Español)
Use these forms if you would like to disenroll from your existing Summit Health plan.
Disenrollment Form (En Español)
You can make your plan monthly premium payment by:
Electronic Funds Transfer (EFT) from your bank
Summit Health eBill. You can use eBill by logging in to your Member Dashboard. If you do not have a Member Dashboard account, you can create one on the Member Dashboard.
Make the check payable to Summit Health Plan, Inc., to:
Summit Health Plan, Inc.
Attn: Medicare Membership Accounting
P.O. Box 4529
Portland, OR 97208-4529
Make sure to put the member ID number for the account(s) to which you want the payment applied on the check.
Deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check. The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. How premium is collected for months prior to the start of withholding depends on when your application is received and the effective date of enrollment. In some cases, Social Security/RRB deducts for those months once withholding begins. It’s important to note that this means premium for multiple months may be deducted from a single benefit check. In other cases, you will receive paper bills and be responsible to pay us directly for months prior to the start of withholding. If Social Security or RRB does not approve your request for automatic deduction, we will send you paper bills for your monthly premiums on an ongoing basis.
Please note: You must continue to pay your Medicare Part B premium.
Last updated Oct. 1, 2024
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Call 844-827-2355 (TTY users, please call 711).
Our customer service team is available from 7 a.m.– 8 p.m. (Pacific Time), seven days a week October 1 – March 31 (closed on Thanksgiving and Christmas), and weekdays April 1 – September 30. Your call will be handled by our automated phone systems outside business hours.