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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, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill, OR: Clark, WA
Violet 1 (PPO) H5439 - 011
  • Benton, Clackamas, Lane, Linn, Marion, Multnomah,
    Polk, Washington and Yamhill, 
  • OR; Clark, WA
Violet 1 (PPO)

H5439 - 013

  • OR; Douglas, Jackson, Josephine
Violet 2 (PPO)

H5439 - 014-001
 

 

 

  • OR: Clackamas, Lane, Multnomah, Washington



 

Violet 2 (PPO) H5439 - 014-002
  • OR: Benton, Linn, Yamhill
Violet 2 (PPO) H5439 - 014-003
  • OR: Marion, Polk
Violet 2 (PPO) H5439 - 014-004
  • WA: Clark
Violet 2 (PPO)

H5439 - 016-001
 

 

  • OR: Jackson


Violet 2 (PPO)

H5439 - 016-002
  • OR: Douglas and Josephine
Violet 3 (PPO) H5439 - 015
  • OR: Douglas and Josephine
Violet 4 (PPO) H5439 - 017
  • OR: Lane

 

For HMO Members

Plans  CMS#  County  Summary of Benefits 
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  Evidence of Coverage
Aqua (PPO)

H5439 - 010

 

 

  • Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill,
    OR; Clark, WA
Violet 1 (PPO) H5439 - 011


  • Benton, Clackamas, Lane, Linn,
    Marion, Multnomah, Polk,
    Washington and Yamhill, OR; Clark, WA
Violet 1 (PPO) H5439 - 013
  • OR: Douglas, Jackson, Josephine
Violet 2 (PPO) H5439 - 014-001
  • OR: Clackamas, Lane, Multnomah, Washington
Violet 2 (PPO) H5439 - 014-002
  • OR: Benton, Linn, Yamhill
Violet 2 (PPO) H5439 - 014-003
  • OR: Marion, Polk
Violet 2 (PPO) H5439 - 014-004
  • WA: Clark
Violet 2 (PPO) H5439 - 016-001
  • OR: Jackson
Violet 2 (PPO) H5439 - 016-002
  • OR: Douglas and Josephine
Violet 3 (PPO) H5439 - 015
  • OR: Douglas and Josephine
Violet 4 (PPO) H5439 - 017
  • OR: Lane

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 and H5439 - 012
  • Benton, Clackamas, Lane, Linn,
    Marion, Multnomah, Polk, Washington, Yamhill, OR: Clark, WA
  • 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
Ruby (HMO) H6815 - 006
  • Coos, Crook, Deschutes, Jefferson


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
Violet 4 (PPO) H5439 - 017
  • Lane

 

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

 

For PPO Members

Plans CMS# County  Extra Benefits Brochure
Aqua (PPO)

H5439 - 010

 

 

  • Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill,
    OR; Clark, WA
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
  • OR: Jackson
Violet 2 (PPO) H5439 - 016-002
  • OR: Douglas and Josephine
Violet 4 (PPO) H5439 - 017
  • Lane

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
  • Supplemental Dental Codes List (PDF) - coming soon

Procedure Code

Procedure Description

C9050

EMAPALUMAB-LZSG

J0129

ABATACEPT INJECTION

J0178

AFLIBERCEPT INJECTION

J0584

BUROSUMAB-TWZA 1M

J0585

ONABOTULINUMTOXINA

J0604

CINACALCET, ESRD ON DIALYSIS

J0717

CERTOLIZUMAB PEGOL INJ 1MG

J0800

CORTICOTROPIN INJECTION

J0897

DENOSUMAB INJECTION

J1300

ECULIZUMAB INJECTION

J1428

ETEPLIRSEN, 10 MG

J1459

IVIG PRIVIGEN 500 MG

J1555

CUVITRU, 100 MG

J1556

IMM GLOB BIVIGAM, 500MG

J1557

GAMMAPLEX INJECTION

J1559

HIZENTRA INJECTION

J1561

GAMUNEX-C/GAMMAKED

J1566

IMMUNE GLOBULIN, POWDER

J1568

OCTAGAM INJECTION

J1569

GAMMAGARD LIQUID INJECTION

J1572

FLEBOGAMMA INJECTION

J1575

HYQVIA 100MG IMMUNEGLOBULIN

J1599

IVIG NON-LYOPHILIZED, NOS

J1602

GOLIMUMAB FOR IV USE 1MG

J1745

INFLIXIMAB (REMICADE)

J1930

LANREOTIDE INJECTION

J2323

NATALIZUMAB INJECTION

J2350

OCRELIZUMAB, 1 MG

J2353

OCTREOTIDE INJECTION, DEPOT

J2357

OMALIZUMAB INJECTION

J2503

PEGAPTANIB SODIUM INJECTION

J2778

RANIBIZUMAB INJECTION

J3262

TOCILIZUMAB, 1 MG

J3304

TRIAMCINOLONE ACE XR 1MG

J3357

USTEKINUMAB SUB CU 1 MG

J3380

VEDOLIZUMAB

J3396

VERTEPORFIN INJECTION

J7189

FACTOR VIIA

J7318

DUROLANE 1 MG

J7320

GENVISC 850, 1MG

J7321

HYALGAN SUPARTZ VISCO-3 DOSE

J7322

HYMOVIS INJECTION 1 MG

J7323

EUFLEXXA INJ PER DOSE

J7324

ORTHOVISC INJ PER DOSE

J7325

SYNVISC OR SYNVISC-ONE

J7326

GEL-ONE

J7327

MONOVISC INJ PER DOSE

J7328

GELSYN-3 INJECTION 0.1 MG

J7329

TRIVISC 1 MG

J9022

ATEZOLIZUMAB,10 MG

J9145

INJECTION DARATUMUMAB 10 MG

J9173

DURVALUMAB, 10 MG

J9176

ELOTUZUMAB, 1MG

J9308

RAMUCIRUMAB

J9311

RITUXIMAB, HYALURONIDASE

J9355

TRASTUZUMAB INJECTION

Q2043

SIPULEUCEL-T AUTO CD54+

Q5103

INFLIXIMAB (INFLECTRA)

Q5104

INFLIXIMAB (RENFLEXIS)

 

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