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 100% Preventative Care as per Healthcare Reform PPO Providers 80% benefit $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-PPO 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	*Formulary plan, see Preferred Product List -subject to change without notice* Review updated list in the Forms Library webpage or Prescription Solutions website. Participating retail pharmacy, 30 day supply* Generic $10 co-pay Preferred List 30% with minimum $25 and maximum $55 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 $50 and maximum $110 co-pay Non-preferred 30% with minimum $90 and maximum $150 co-pay
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 Customer Service (800) 813-2000	Kaiser Permanente Health Plan of the Northwest provider panel 2011 $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% Preventative Care and immunizations $15 co-pay routine eye exams $250 vision hardware with Kaiser Permanente 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 $15 co-pay Generic $30 co-pay Brands 90 day supply-Mail Order $30 co-pay Generic $60 co-pay Brands 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.	www.kaiserpermanente.org website Kaiser Permanente 800-813-2000