Forms and Brochures

PPO Plans

• PPO Platinum P10-250-1-4000LX Plan Overview – English (PDF)
• PPO Platinum P10-500-1-4000LX Plan Overview – English (PDF)
• PPO Platinum P10-750-2-3500LX Plan Overview – English (PDF)
• PPO Gold P50-0-5-5000 Plan Overview – English (PDF)
• PPO Gold P0-1500-4-8000DX Plan Overview – English (PDF)
• PPO Gold P0-3500-4-8000DX Plan Overview – English (PDF)
• PPO Gold P20-500-3-7900DX Plan Overview – English (PDF)
• PPO Gold P20-1000-2-7950DX Plan Overview – English (PDF)
• PPO Gold P20-2000-2-7900DX Plan Overview – English (PDF)
• PPO Gold P20-2500-3-7900DX Plan Overview – English (PDF)
• PPO Gold P30-1500-2-7900DX Plan Overview – English (PDF)
• PPO Gold P30-3500-3-7900DX Plan Overview – English (PDF)
• PPO Silver P35-5000-5-8500DX Plan Overview – English (PDF)
• PPO Silver P45-3500-5-8150ES Plan Overview – English (PDF)
• PPO Silver P45-4000-3-8150ES Plan Overview – English (PDF)
• PPO Silver P45-5000-5-8150ES Plan Overview – English (PDF)
• PPO Silver P45-6000-5-8500ES Plan Overview – English (PDF)
• PPO Bronze P8250-0-8250ES Plan Overview – English (PDF)

PPO High Deductible Plans

• PPO High Deductible Silver HD3000-3-6750ES Plan Overview – English (PDF)
• PPO High Deductible Silver HD4000-3-6750ES Plan Overview – English (PDF)
• PPO High Deductible Bronze HD6900-0-6900ES Plan Overview – English (PDF)

PPO Standard Plans

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

CommunityCare 1T Plans

Available to Oregon groups located in Multnomah, Clackamas, Washington, Clatsop, Columbia, and Tillamook counties.

• CommunityCare 1T 15-500-1-3000DX Plan Overview (PDF)
• CommunityCare 1T 20-750-2-3000DX 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)

PPO Plans

Available to Oregon groups statewide.

• PPO Platinum P10-250-1-4000LX Plan Overview (PDF)
• PPO Platinum P10-500-2-4000LX Plan Overview (PDF)
• PPO Platinum P10-750-2-4000LX Plan Overview (PDF)
• PPO Gold P50-0-5-5000 Plan Overview (PDF)
• PPO Gold P0-1500-4-7900DX Plan Overview (PDF)
• PPO Gold P0-3500-4-7900DX Plan Overview (PDF)
• PPO Gold P20-500-3-7900DX 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 P20-5000-5-8150DX 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 P8250-0-8250ES Plan Overview (PDF)

PPO High Deductible Plans

Available to Oregon groups statewide.

• PPO High Deductible Silver HD2800-2-5500ES Plan Overview (PDF)
• PPO High Deductible Silver HD3000-3-6750ES Plan Overview (PDF)
• PPO High Deductible Silver HD4000-3-6750ES Plan Overview (PDF)
• PPO High Deductible Bronze HD6900-0-6900ES Plan Overview (PDF)

PPO Standard Plans

Available to Oregon groups statewide.

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

Sample Plan Contract and Benefit Schedule

• CommunityCare 1T 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)

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)