Medical


For Services incurred prior to January 1, 2011 the PPO plan Third Party Administrator is HMA and WHI. For Services effective January 1, 2011 the TPA for the PPO plan has changed to UMR & Prescription Solutions.

Plan

Summary

PPO

UMR

Customer Service members 866-868-7758

24/7 Nurseline 866-494-4502

Provider services 877-233-1800

United Healthcare Options PPO Network

$250 deductible per person, per calendar year or
$750 family deductible per calendar year

Preferred Providers

80% benefit
100% Routine Preventative Care and immunizations
$1,250 annual out of pocket maximum per person, per calendar year (includes deductible) or
$3,750 family annual out of pocket maximum per calendar year

Non-Preferred providers

60% benefit
$2,250 annual out of pocket maximum per person, per calendar year (includes deductible) or
$6,750 family annual out of pocket maximum per calender year

Alternative Care benefits: Chiropractic, Acupuncture, and Naturopathic care $10 co-pay each visit with an combined maximum of $500 per calendar year for all services: . Preferred and Non-Preferred providers.

See the UMR Plan Document for full details.

Prescription Drugs

Prescription Solutions

Customer Service and mail order

877-559-2955

Participating retail pharmacy

Formulary plan, see Preferred Product List -subject to change without notice

Review updated list in the Forms Library webpage, Prescription Solutions website or contact Prescription Solutions customer service.

30 day supply

Generic- $10 co-pay
Preferred list- 30% with minimum $25 and maximum $50 co-pay
Non-preferred- 30% with minimum $45 and maximum $75 co-pay

Mail order, 90 day supply

Generic- $20 co-pay
Preferred list- 30% with minimum $25 and maximum $100
Non-preferred- 30% with minimum $45 and maximum $120

Forms/Documents

Links

All forms related to this plan can be found in the benefits Forms Library.Click Here to go to the Forms Library.

Please see the Forms Library for the current Preferred Product list

www.umr.com

www.prescriptionsolutions.com

www.umr.com/oss/cms/umr/Options_PPO_Exclusions.html Preferred Provider search

Plan	Summary
HMO Kaiser Permanente *Kaiser Permanente* Customer Service (800) 813-2000	Kaiser Permanente Health Plan of the Northwest provider panel $250 deductible per person, per calendar year or $750 per family $2,000 annual out of pocket maximum per person, per calendar year or $6,000 per family $15 co-pay for Primary Care $25 co-pay for Specialty Care 100% Routine Preventative care and routine immunizations $15 co-pay routine eye exams $500 vision hardware every 24 months Alternative Care benefit: Chiropractic, Acupuncture and Naturopathic care $10 co-pay each visit. Massage Therapy $25 co-pay each visit, maxium 12 visits per calendar year. Combined $1,000 calendar year maximum benefit for all services. Most other services are paid at 80% after deductible has been met. Prescription Drugs 30 day supply-Generic $15 co-pay, Brands $30 co-pay 90 day supply home delivery-Generic $30 co-pay, Brands $60 co-pay See the Kaiser Plan Document for full details.
Forms/Documents	Links
All forms related to this plan can be found in the benefits Forms Library. Click Here to go to the Forms Library.	Kaiser Permanente website