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Plan Materials and Forms

For PPO Members

Plans CMS# County  Summary of Benefits
Aqua (PPO)

H5439 - 010

H5439 - 012

  • Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill, OR: Clark, WA

  • Douglas, Jackson and Josephine
Violet 1 (PPO)

H5439 - 011

H5439 - 013

  • Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington and Yamhill, OR; Clark, WA

  • Douglas, Jackson, Josephine
Violet 2 (PPO)

H5439 - 014-001

H5439 - 014-002

H5439 - 014-003

H5439 - 014-004

H5439 - 016-001

H5439 - 016-002

 

  • OR: Clackamas, Lane, Multnomah, Washington

  • Benton, Linn, Yamhill

  • Marion, Polk

  • WA: Clark

  • Jackson

  • Douglas and Josephine
Violet 3 (PPO) H5439 - 015
  • Douglas and Josephine

 

For HMO Members

Plans  CMS#  County  Summary of Benefits 
Ruby (HMO)

H6815 - 003-001

H6815 - 003-002

H6815 - 005

  • Clackamas, Lane, Multnomah & Washington

  • Benton, Linn, Marion, Polk & Yamhill

  • Douglas, Jackson, Josephine

For PPO Members

Plans CMS# County  Annual Notice of Changes
Aqua (PPO)

H5439 - 010

H5439 - 012

  • Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill, OR: Clark, WA

  • Douglas, Jackson and Josephine
Violet 1 (PPO)

H5439 - 011

H5439 - 013

  • Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington and Yamhill, OR; Clark, WA

  • Douglas, Jackson, Josephine
Violet 2 (PPO) H5439 - 014-001
  • OR: Clackamas, Lane, Multnomah, Washington

 

Violet 2 (PPO) H5439 - 014-002
  • Benton, Linn, Yamhill
Violet 2 (PPO) H5439 - 014-003
  • Marion, Polk
Violet 2 (PPO) H5439 - 014-004
  • WA: Clark
Violet 2 (PPO) H5439 - 016-001
  • Jackson
Violet 2 (PPO) H5439 - 016-002
  • Douglas and Josephine
Violet 3 (PPO) H5439 - 015
  • Douglas and Josephine

 

For HMO Members

Plans  CMS#  County  Annual Notice of Changes
Ruby (HMO) H6815 - 003-001
  • Clackamas, Lane, Multnomah & Washington
Ruby (HMO) H6815 - 003-002
  • Benton, Linn, Marion, Polk & Yamhill

For PPO Members

Plans CMS# County  Evidence of Coverage
Aqua (PPO)

H5439 - 010

H5439 - 012

  • Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill, OR: Clark, WA

  • Douglas, Jackson and Josephine
Violet 1 (PPO)

H5439 - 011

H5439 - 013

  • Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington and Yamhill, OR; Clark, WA

  • Douglas, Jackson, Josephine
Violet 2 (PPO) H5439 - 014-001
  • OR: Clackamas, Lane, Multnomah, Washington
Violet 2 (PPO) H5439 - 014-002
  • Benton, Linn, Yamhill
Violet 2 (PPO) H5439 - 014-003
  • Marion, Polk
Violet 2 (PPO) H5439 - 014-004
  • WA: Clark
Violet 2 (PPO) H5439 - 016-001
  • Jackson
Violet 2 (PPO) H5439 - 016-002
  • Douglas and Josephine
Violet 3 (PPO) H5439 - 015
  • Douglas and Josephine

For HMO Members

Plans  CMS#  County  Summary of Benefits 
Ruby (HMO) H6815 - 003-001
  • Clackamas, Lane, Multnomah & Washington
Ruby (HMO) H6815 - 003-002
  • Benton, Linn, Marion, Polk & Yamhill
Ruby (HMO) H6815 - 005
  • Douglas, Jackson, Josephine

For PPO Members

Plans CMS# County  LIS Premium Charts
Violet 1 (PPO) H5439 - 011
  • Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington and Yamhill, OR; Clark, WA
Violet 1 (PPO)

H5439 - 013

  • Douglas, Jackson, Josephine
Violet 2 (PPO) H5439 - 014-001
  • OR: Clackamas, Lane, Multnomah, Washington
Violet 2 (PPO) H5493 - 014-002
  • Benton, Linn, Yamhill
Violet 2 (PPO) H5439 - 014-003
  • Marion, Polk
Violet 2 (PPO) H5439 - 014-004
  • WA: Clark
Violet 2 (PPO) H5439 - 016-001
  • Jackson
Violet 2 (PPO) H5439 - 016-002
  • Douglas and Josephine
Violet 3 (PPO) H5439 - 015
  • Douglas and Josephine

 

For HMO Members

Plans  CMS#  County  Summary of Benefits 
Ruby (HMO) H6815 - 003-001
  • Clackamas, Lane, Multnomah & Washington
Ruby (HMO) H6815 - 003-002
  • Benton, Linn, Marion, Polk & Yamhill
Ruby (HMO)

H6815 - 005

  • Douglas, Jackson, Josephine

Mail Order Pharmacy

2018 Preferred Diabetes Testing Supplies

Medication Therapy Management

Prescription Claims

HMO Star Ratings