Unrepresented Employees Medical Summary

Provider

Summary

PPO

Healthcare Management Administrators (HMA)

Regence BlueCross BlueShield of Oregon and Washington's provider panel

$100 deductible per person, per calendar year or

$300 family deductible per calendar year 

$2,000,000 Lifetime Maximum

PPO Providers

• 80% benefit

• $1,100 annual out of pocket maximum per person, per calendar year (includes deductible) or

• $2,100 family annual out of pocket maximum per   calendar year

Non-PPO providers

• 60% benefit

• $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

Plan also includes: routine examinations, immunizations and limited complementary care.  See benefit summary for details.

Prescription Drugs

Walgreens Health Initiatives (WHI)

Participating retail pharmacy

WHI mail order

• 90 day supply

• $20 or the cost which ever is less

Forms/Documents

Links

HMA Summary Plan Document

HMA Benefit Summary

HMA claim form

HMA online instructions to access benefits and claims

WHI mail order form

WHI Preferred Medication List

Provider

Summary

HMO

Kaiser Permanente

Kaiser Permanente Health Plan of the Northwest  provider panel

• $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

• $2,000,000 lifetime maximum

• $15 co-payment for Primary Care

• $25 co-payment for Specialty Care

• Services in which deductible apply are paid at 80% after deductible has been met.

• Includes – preventive care, immunizations and routine vision exam.

Forms/Documents

Links

KP Summary of Benefits