Welcome to Summit Health
The resources you need to manage your plan and benefits.
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File a claim
Formulary
Medication Therapy Management
Prior authorization
Prescription drug coverage determination
Plan materials
Appeals and grievances
Star ratings
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.
Our Medication Therapy Management (MTM) program can help members who qualify get the most benefits from the drugs they are taking. MTM is free. To qualify for MTM, you need to have three or more of these chronic conditions:
You also need to:
We will review your medication usage each quarter. If we see that you qualify, we will enroll you in the program. Then, we will send you an invitation to talk about your medications with one of our pharmacists or other health professionals.
If you accept the invite, we will set up a comprehensive medication review (CMR). This usually takes 30 – 60 minutes. After the CMR, you will receive a Medication Action Plan (MAP). The action plan has steps you should take to help you get the best results from your medications. You will also receive a Personal Medication List (PML), which will help you keep track of your medications and how to use them the right way. You can use this action plan and medication list to show your healthcare providers all of the medications you are taking.
Obtain a blank copy of the Personal Medication List (PML)
MTM also includes a targeted medication review (TMR). A TMR identifies any ways your medication use can be improved for your safety. If we notice any, we will contact the provider who prescribed the drugs and ask them to make any needed changes.
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:
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:
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)
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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.