Downloadable Forms and Documents

CommunityCare 1T Plans

Multnomah, Clackamas, Washington, Clatsop, Columbia and Tilamook counties

• CommunityCare 1T 25-750-2-3000DX Plan Overview (PDF)
• CommunityCare 1T 25-1000-2-7900DX Plan Overview (PDF)
• CommunityCare 1T 25-2000-2-7900DX Plan Overview (PDF)
• CommunityCare 1T 25-3500-2-7900DX Plan Overview (PDF)
• CommunityCare 1T 40-3000-3-8150ES Plan Overview (PDF)
• CommunityCare 1T 40-4500-3-8150ES Plan Overview (PDF)
  

CommunityCare 3T Plans

Multnomah, Clackamas, Washington, Clatsop, Columbia and Tilamook counties

• CommunityCare 3T 25-750-2-3000DX Plan Overview (PDF)
• CommunityCare 3T 25-1000-2-7900DX Plan Overview (PDF)
• CommunityCare 3T 25-2000-2-7900DX Plan Overview (PDF)
• CommunityCare 3T 25-3500-2-7900DX Plan Overview (PDF)
• CommunityCare 3T 40-3000-3-8150ES Plan Overview (PDF)
• CommunityCare 3T 40-4500-3-8150ES Plan Overview (PDF)
  

PPO Plans

• PPO Platinum P10-250-1-4000LX Plan Overview (PDF)
• PPO Platinum P20-500-2-4000LX Plan Overview (PDF)
• PPO Platinum P20-750-2-4000LX Plan Overview (PDF)
• PPO Gold P20-1000-2-7900DX Plan Overview (PDF)
• PPO Gold P20-2000-2-7900DX Plan Overview (PDF)
• PPO Gold P20-2500-3-7900DX Plan Overview (PDF)
• PPO Gold P30-1500-2-7900DX Plan Overview (PDF)
• PPO Gold P30-3500-3-7900DX Plan Overview (PDF)
• PPO Silver P40-3000-3-8150ES Plan Overview (PDF)
• PPO Silver P40-4000-3-8150ES Plan Overview (PDF)
• PPO Silver P45-3500-5-8150ES Plan Overview (PDF)
• PPO Silver P45-5000-5-8150ES Plan Overview (PDF)
• PPO Bronze P75-5000-5-8150ES Plan Overview (PDF)
• PPO Bronze P7350-0-7350ES Plan Overview (PDF)

PPO High Deductible Plans

• PPO High Deductible Silver HD2800-2-5500ES Plan Overview (PDF)
• PPO High Deductible Bronze HD6550-0-6550ES Plan Overview (PDF)
  

PPO Standard Plans

• Oregon Standard Gold Plan Plan Overview (PDF)
• Oregon Standard Silver Plan Plan Overview (PDF)
• Oregon Standard Bronze Plan Plan Overview (PDF)

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)
• PPO Standard Plans Contract and Benefit Schedule (PDF)

CommunityCare 1T Plans

Multnomah, Clackamas, Washington, Clatsop, Columbia and Tilamook counties

• CommunityCare 1T 25-750-2-3000DX Plan Overview (PDF)
• CommunityCare 1T 25-1000-2-6500DX Plan Overview (PDF)
• CommunityCare 1T 25-2000-2-6500DX Plan Overview (PDF)
• CommunityCare 1T 30-3500-2-6500DX Plan Overview (PDF)
• CommunityCare 1T 30-3000-3-7900ES Plan Overview (PDF)
• CommunityCare 1T 30-4500-2-7900ES Plan Overview (PDF)
  

CommunityCare 3T Plans

Multnomah, Clackamas, Washington, Clatsop, Columbia and Tilamook counties

• CommunityCare 3T 25-750-2-3000DX Plan Overview (PDF)
• CommunityCare 3T 25-1000-2-6500DX Plan Overview (PDF)
• CommunityCare 3T 25-2000-2-6500DX Plan Overview (PDF)
• CommunityCare 3T 30-3500-2-6500DX Plan Overview (PDF)
• CommunityCare 3T 30-3000-3-7900ES Plan Overview (PDF)
• CommunityCare 3T 30-4500-2-7900ES Plan Overview (PDF)
  

PPO Plans

• PPO Platinum P20-500-2-4000LX Plan Overview (PDF)
• PPO Platinum P20-750-2-4000LX Plan Overview (PDF)
• PPO Gold P20-1000-2-7900DX Plan Overview (PDF)
• PPO Gold P20-2000-2-7900DX Plan Overview (PDF)
• PPO Gold P20-2500-3-7900DX Plan Overview (PDF)
• PPO Gold P30-1500-2-7900DX Plan Overview (PDF)
• PPO Gold P30-3500-3-7900DX Plan Overview (PDF)
• PPO Silver P30-3000-3-7900ES Plan Overview (PDF)
• PPO Silver P30-4000-3-7900ES Plan Overview (PDF)
• PPO Silver P40-5000-3-7900ES Plan Overview (PDF)
• PPO Bronze P75-5000-5-7900ES Plan Overview (PDF)
• PPO Bronze P7350-0-7350ES Plan Overview (PDF)

PPO High Deductible Plans

• PPO High Deductible Silver HD2700-2-5500ES Plan Overview (PDF)
• PPO High Deductible Bronze HD6550-0-6550 Plan Overview (PDF)
  

PPO Standard Plans

• Oregon Standard Gold Plan Plan Overview (PDF)
• Oregon Standard Silver Plan Plan Overview (PDF)
• Oregon Standard Bronze Plan Plan Overview (PDF)

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)
• PPO Standard Plans Contract and Benefit Schedule (PDF)

PPO Plan Overviews

• Platinum W25-750-2-2500LX Plan Overview (PDF)
• Platinum W25-1000-2-3000LX Plan Overview (PDF)
• Gold W40-1500-2-6000DX Plan Overview (PDF)
• Gold W40-2500-2-6000DX Plan Overview (PDF)
• PPO Gold W40-3500-2-7000DX Plan Overview (PDF)
• Silver W45-4500-3-7350ES Plan Overview (PDF)
• Silver W55-5500-3-7350ES Plan Overview (PDF)
• Silver W6000-3-7000ES Plan Overview (PDF)
• Silver HD2700-2-6550ES Plan Overview (PDF)
• Bronze W75-5000-5-7900ES Plan Overview (PDF)
• Bronze W7350-0-7350ES Plan Overview (PDF)
• Bronze HD6550-0-6550ES Plan Overview (PDF)

Sample Plan Contract and Benefit Schedule

• Washington PPO Plans Contract and Benefit Schedule (PDF)

Oregon

Oregon Essential Rx Drug List (PDF)

Washington

• Washington Essential Rx Drug List (PDF)
• Medications Qualifying for Emergency Fill (PDF)
• Medications Excluded from Emergency Fill (PDF)