Skip to Main Content

Plan Materials and Forms

Listed below are some documents that may be helpful at different times during your membership.  

For PPO Members

Plans CMS# County  Summary of Benefits
Aqua (PPO) H5439 - 010
  • Benton, Clackamas, Lane,
    Linn, Marion, Multnomah, Polk, Washington, Yamhill, OR: Clark, WA
Aqua (PPO)

H5439 - 012

  • Douglas, Jackson and Josephine
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) 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

H6815 - 003-002

H6815 - 003-003

  • Clackamas, Multnomah & Washington

  • Benton, Linn, Marion, Polk & Yamhill

  • Lane 
Ruby (HMO)
H6815 - 005
  • Douglas, Jackson, Josephine
Ruby (HMO)
H6815 - 006
  • Coos, Crook, Deschutes, Jefferson

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  Evidence of Coverage 
Ruby (HMO) H6815 - 003-001
  • Clackamas, Multnomah & Washington
Ruby (HMO) H6815 - 003-002
  • Benton, Linn, Marion, Polk & Yamhill
Ruby (HMO) H6815 - 003-003
  • Lane
Ruby (HMO) H6815 - 005
  • Douglas, Jackson, Josephine
Ruby (HMO) H6815 - 006
  • Coos, Crook, Deschutes, Jefferson

For PPO Members

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

H5439 - 010

 

  • Benton, Clackamas, Lane, Linn,
    Marion, Multnomah, Polk, Washington, Yamhill, OR: Clark, WA
Aqua (PPO)

H5439 - 012

  • Douglas, Jackson and Josephine
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) 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, Multnomah & Washington
Ruby (HMO) H6815 - 003-002
  • Benton, Linn, Marion, Polk & Yamhill
Ruby (HMO) H6815 - 003-003
  • Lane
Ruby (HMO) H6815 - 005
  • Douglas, Jackson, Josephine


For PPO Members

Plans CMS# County  Low Income Subsidy
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) 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  Low Income Subsidy
Ruby (HMO) H6815 - 003-001
  • Clackamas,
    Multnomah & Washington
Ruby (HMO) H6815 - 003-002
  • Benton, Linn, Marion,
    Polk & Yamhill
Ruby (HMO) H6815 - 003-003
  • Lane
Ruby (HMO) H6815 - 005
  • Douglas, Jackson, Josephine
Ruby (HMO) H6815 - 006
  • Coos, Crook, Deschutes, Jefferson

 

 

Can't find what you need? Contact Member Services. We are here to help!