Medical


For Services incurred prior to January 1, 2011 the PPO plan 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

2011

100 deductible per person, per calendar year or
$300 family deductible per calendar year

2012

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

Preferred Providers

80% benefit
2011 $1,100 annual out of pocket maximum per person, per calendar year (includes deductible) or $3,300 family annual out of pocket maximum per calendar year
2012 $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
2012 100% Routine Preventative Care and immunizations

Non-Preferred providers

60% benefit
2011 $2,100 annual out of pocket maximum per person, per calendar year (includes deductible) or $6,300 family annual out of pocket maximum per calender year
2012 $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 web page or Prescription Solutions website website.

2011

30 day supply

$10 co-pay - generic
$20 co-pay - preferred list
$50 co-pay - non-preferred
Or the price of the drug, whichever is less

Mail order, 90 day supply

$20 co-pay - generic
$40 co-pay - preferred list
$100 co-pay - non-preferred
Or the price of the drug, whichever is less

2012

30 day supply

Generic $10 co-pay
Preferred List 30% with a minimum $25 and maximum $55
Non-Preferred 30% with minimum $45 and maximum $75
Mail order, 90 day supply
Generic $20 co-pay
Preferred List 30% with a minimum $50 and maximum $110
Non-Preferred 30% with minimum $90 and maximum $150

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 2011 $150 deductible per person, per calendar year or $450 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 $15 co-pay Preventative care $15 co-pay routine eye exams Vision hardware benefit with PPO plan Most other services are paid at 80% after deductible has been met. Prescription Drugs 30 day supply, $15 co-pay 90 day supply home delivery, $30 co-pay 2012 $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 immunizations $15 co-pay routine eye exams $250 Vision hardware benefit 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 website