Sample Coverage Documents

These sample coverage documents are provided for your consideration, as required by state and/or federal health insurance regulators. Please note these documents are samples only.

Oregon Sample Plan Contract and Benefit Schedule

• CommunityCare 1T Plans Contract and Benefit Schedule (PDF)
• CommunityCare 3T Plans Contract and Benefit Schedule (PDF)
• PPO Plans Contract and Benefit Schedule (PDF)
• PPO HDHP Plans Contract and Benefit Schedule (PDF)

Washington Sample Plan Contract and Benefit Schedule

• Washington PPO Plans Contract and Benefit Schedule (PDF)