INDIVIDUALS & FAMILIES Plan Overview

Transcription

1 INDIVIDUALS & FAMILIES 2019 Plan Overview

2 Your partner in health and wellness Resources to keep you well Our FitTogether wellness programs and services include: Access to ProvRN for free health advice, 24/7, from a registered nurse Programs to help tobacco s quit for good Award-winning care managers who provide education and support for chronic conditions, such as asthma and diabetes Classes to help you manage stress, achieve a healthy weight, begin a yoga practice and more An award-winning newsletter packed with health and wellness information from Providence health experts Tools to maintain and improve health With myprovidence, your secure member portal for health, wellness and benefits information, you can: Get a baseline of your overall health with a personal health assessment Improve your health with Wellness Central, which offers a personalized dashboard featuring health trackers and videos, articles, meal plans and medical information Search the online directory to find in-network providers, review your claims history and calculate how much of your deductible you ve met New for 2019 ID Protection *. With Assist America s Identity Theft Protection, eligible members who enroll are protected from the often devastating consequences of identity theft. This program provides tools to help prevent theft of personal data and restore the integrity of personal data if it is used fraudulently. Travel Assistance *. Providence members can enjoy complete peace of mind, free from dealing 2 with complex decisions and financial considerations than 9,000 participating fitness centers nationally, and 3 during difficult times away from home. With a single phone call to Assist America, members get access Manage your health costs with our treatment cost calculator and online bill pay options Order a replacement member ID card and view your Oregon Individual Plan Contract Health-enhancing extras for better fitness and more fun Providence Health Plan members get exclusive recreation discounts through LifeBalance for: - Popular local and national family attractions, such as zoos and amusement parks - Hundreds of fitness facilities throughout Oregon - Discounted tickets to local events, savings at hotels nationwide and more Board-certified LASIK vision correction or custom LASIK through our partner, TruVision Alternative care options You can see a naturopath for covered benefits, including periodic exams and well-baby care. These services are covered at the same rate as they would be for a primary care provider, as long as the naturopath is licensed to perform the services. With the Connect plan, chiropractic manipulation and acupuncture are covered with a $25 copay when you use an in-network provider (3 combined visits per year). to a unique global emergency assistance program. It immediately connects you to doctors, hospitals, pharmacies and other services if you experience a medical or non-medical emergency while traveling 100 miles away from home or outside the US. Active&Fit Direct TM. Tired of paying expensive health club membership fees? Providence members can save with the Active&Fit Direct program. Choose from more pay just $25 a month (plus a $25 enrollment fee and applicable taxes; 3-month commitment required). With Providence, you can choose from many types of care. This guide can help you decide which type to use in each situation. ProvRN (no cost) Not sure if you need care? Just want advice about what to do next? Talk to a registered nurse by phone for free, 24/7. Always free, always there Call or Primary Care ($$) Want to see someone who knows your health, but it s not urgent? Have a chronic problem, need preventive care or follow-up? See your primary care provider. By appointment Call your primary care clinic Express Care Virtual (no cost * ) Need treatment, but have a fairly simple problem and want to stay home? Have a virtual visit with a provider from your phone, tablet or computer. Open 8 a.m. to midnight, seven days a week Go to ProvidenceHealthPlan.com/ virtualvisit Urgent Care ($$$) Know you need help right away, but don t think you are in immediate danger? Urgent care can deal with things like minor cuts and burns, infections and more. Seen according to urgency of problem Visit an urgent care facility near you Express Care Clinics (no cost * ) Need same-day treatment when it s not an emergency? Want to be seen in person? Find a clinic in Portland, including inside many Walgreens. Same-day appointments, seven days a week Visit ProvidenceExpresscare.org Emergency ($$$$) Think your life may be in danger? Maybe you have signs of heart attack, stroke, uncontrolled bleeding or unbearable pain? You need the E.R. Call Get a ride to the nearest hospital *No cost for Providence members. *HSA Qualified 6650 Bronze plan members must first meet their deductible.

3 Selling areas To apply for a Providence Individual and Family plan, you must reside in our selling area for the selected plan type (counties indicated below). Please note that the selling area for each plan may be different from the provider network. See the plan pages for the provider network maps. Connect plans Washington Yamhill Multnomah Clackamas Standard and HSA Qualified plans Available in these counties: Clackamas,, Multnomah, Washington, Yamhill (zip code only) Where to buy plans Purchase the right Providence plan for you at ProvidenceHealthPlan.com/shop, or ask a Providence representative or your insurance producer for help. Providence plans are also available through the Federal Health Insurance Marketplace at HealthCare.gov. Plan name and metal tier Plans available directly from Providence or your producer Plans available from the Federal Health Insurance Marketplace at HealthCare.gov Connect 2500 Silver Connect 7900 Bronze Providence Oregon Standard Gold Plan - Signature Network Providence Oregon Standard Silver Plan - Signature Network Providence Oregon Standard Bronze Plan - Signature Network Providence Oregon Standard Gold Plan - Choice Network Providence Oregon Standard Silver Plan - Choice Network Providence Oregon Standard Bronze Plan - Choice Network HSA Qualified 6650 Bronze - Signature Network HSA Qualified 6650 Bronze - Choice Network Providence Progressive Dental Plan Compare plans See rates Apply and enroll Coos Curry Lincoln Clatsop Tillamook Yamhill Polk Benton Douglas Columbia Marion Linn Lane Jackson Washington Multnomah Clackamas Klamath Wasco Jefferson Sherman Crook Choice Network Gilliiam Wheeler Lake Morrow Umatilla Providence Progressive Dental plan Grant Harney Union Baker Wallowa Malheur Signature Network Available in these counties: Choice Network: Benton, Clackamas, Clatsop, Crook,, Douglas,, Jackson, Jefferson, Lane, Lincoln, Linn, Marion, Multnomah, Polk, Washington, Yamhill Signature Network: Baker, Columbia, Coos, Curry, Gilliam, Grant, Harney,, Klamath, Lake, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wallowa, Wasco, Wheeler Shop, see rates, apply and enroll. Let us help find the right plan for you: Online at ProvidenceHealthPlan.com/shop Over the phone with a Providence representative, 8 a.m. to 5 p.m. (Pacific Time) Portland metro area All other areas With your insurance producer When to apply Apply during open enrollment from Nov. 1, 2018 through Dec. 15, After the open enrollment period ends, you must have a qualifying life event to enroll in a health insurance plan. Qualifying life events include losing employer coverage, marriage and the birth of a child. See a list of qualifying life events at ProvidenceHealthPlan.com/qe. 4 This booklet offers an overview of our individual and family plans, which are subject to change every year. For 5 Available in all counties in Oregon more information about plan benefits and enrollment requirements, limitations and exclusions, see the plan contract or contact our sales team or your insurance producer. To view the Summary of Benefits and Coverage (SBC), go to ProvidenceHealthPlan.com/sbc.

4 Connect Connect plans combine a medical home model of care with a tailored provider network. You choose a medical home from our Providence Connect network with this plan. The medical home model provides a team of health professionals that supports all aspects of your overall well-being, from wellness and prevention to helping you manage chronic conditions. Connect plans offer: More than 70 medical home clinics in the Portland metro area No out-of-network benefits are included with this plan. You must use an in-network provider to receive benefits except for emergency and urgent care services Emergency and urgent care services covered in- and out-of-network Access to specialists via referral from the medical home A deductible that applies to the out-of-pocket maximum The option to add dental coverage with the Providence Progressive Dental Plan, as long as you buy a plan directly from Providence Health Plan or through a producer. Providence Progressive Dental is not available through Healthcare.gov Chiropractic manipulation and acupuncture are covered in-network Connect Connect 2500 Silver Connect 7900 Bronze Annual deductible Individual/family $2,500/$5,000 $7,900/$15,800 Annual out-of-pocket maximum Individual/family $7,900/$15,800 $7,900/$15,800 After meeting your deductible, you pay the following amounts for covered services. The deductible does not apply to some covered services. These are marked with. Preventive Care Periodic health exams and well-baby care (from any provider licensed to perform the service) Maternity prenatal office visits Annual gynecological exam and Pap test 6 Deductible is waived for these services. 7 Mammograms Colorectal cancer screenings (preventive age 50 and over) Providence Connect Network: A network of more than 70 primary care clinics in Clackamas, Hood River, Multnomah, Washington and Yamhill (zip code only) counties designated as medical homes Washington Yamhill Multnomah Clackamas For a complete list of medical homes and providers by location, visit ProvidenceHealthPlan.com/ findaprovider. To see if your provider is in one of our medical homes, select "Medical Home Primary Care Providers" under "What type of doctor are you looking for?" when you filter search results. For more information about Providence medical homes, visit ProvidenceHealthPlan.com/medhome. Connect (continued) Office Visits for Medical Services Connect 2500 Silver Connect 7900 Bronze Primary care provider $45 $65 Express Care Virtual and Express Care Clinics Alternative care provider $45 $65 Specialist $65 $125 Hospital Services Inpatient hospital services and maternity care 30% Emergency Emergency services (all emergency services are treated as in-network) Urgent Care Urgent care services (urgent care covered out-ofnetwork, deductible applies) Outpatient Diagnostic Services $250 then 30% $75 X-ray and lab services 30% High-tech imaging services (such as PET, CT, MRI) 30% Mental Health and Chemical Dependency Inpatient and residential services 30% Outpatient provider visits $45 $65 Other Covered Services Outpatient surgery at an ambulatory surgery center or hospital-based facility Chiropractic manipulation and acupuncture (limited to 3 visits combined per calendar year) Prescription Drugs 30% $25 Preferred generic $20 $35 Non-preferred generic $35 $65 Preferred brand name $75 Non-preferred brand name 50% Preferred specialty 50% with a $200 per script cap Non-preferred specialty 50% Pediatric Vision Services (children 18 years and younger) Routine eye exams (one exam per calendar year) Vision hardware (frames, lenses, contact lenses) limits apply Adult Vision Services Routine eye exams (one exam per calendar year) $25 $25 Vision hardware (frames, lenses, contact lenses) Not Covered Not Covered Pediatric Dental Services* (children 18 years and younger) Preventive services (includes routine exams, cleanings, bitewing X-rays, topical fluoride, space maintainers) Basic services (restorative fillings) 50% 50% Major services (includes oral surgery, crowns, periodontics, endodontics, denture and bridge work) * Dental services subject to medical deductible and out-of-pocket maximum. Please visit ProvidenceHealthPlan.com/shop to compare plans, see rates and enroll. 50% 50%

5 Standard Our Standard plans do not include out-of-network benefits. The provider network depends on the county in which you live. You will choose a medical home if your plan is on the Providence Choice network. Standard plans offer: Copays starting as low as $10 and deductibles as low as $1,000 No out-of-network benefits are included with this plan. You must use an in-network provider to receive benefits except for emergency and urgent care services In some counties, your provider network is the Providence Choice Network. In other counties, your provider network is the Providence Signature Network Emergency and urgent care services covered in- and out-of-network Access to specialists via referral from the medical home for Standard plans on the Choice network. No referral needed for Standard plans on the Signature Network The option to add dental coverage with the Providence Progressive Dental Plan, as long as you buy a plan directly from Providence Health Plan or through a producer. Providence Progressive Dental is not available through Healthcare.gov Note: Standard plans do not cover chiropractic manipulation, acupuncture, adult routine vision exams, adult vision hardware, and pediatric dental services. Standard Providence Oregon Standard Gold Providence Oregon Standard Silver Providence Oregon Standard Bronze Annual Deductible Individual/family $1,000/$2,000 $2,850/$5,700 $6,550/$13,100 Annual Out-of-Pocket Maximum Individual/family $6,850/$13,700 $7,900/$15,800 $6,550/$13,100 After meeting your deductible, you pay the following amounts for covered services. The deductible does not apply to some covered services. These are marked with. Preventive Care Periodic health exams and well-baby care (from any provider licensed to perform the service) Maternity prenatal office visits 8 9 Annual gynecological exam and Pap test Mammograms Colorectal cancer screenings (preventive age 50 and over) Providence Choice Network: A network of nearly 300 primary care clinics designated as medical homes Providence Signature Network: A nationwide network of nearly 1 million providers, both in Providence facilities and in other locations Coos Curry Lincoln Clatsop Tillamook Yamhill Polk Benton Douglas Columbia Marion Linn Lane Jackson Washington Multnomah Clackamas Klamath Choice Network Wasco Jefferson For a listing of our Choice or Signature Network providers, visit ProvidenceHealthPlan.com/findaprovider. For more information about Providence medical homes, visit ProvidenceHealthPlan.com/medhome. Sherman Gilliiam Crook Wheeler Lake Morrow Grant Umatilla Harney Union Baker Signature Network Wallowa Malheur Standard (continued) Office Visits for Medical Services Providence Oregon Standard Gold Providence Oregon Standard Silver Providence Oregon Standard Bronze Primary care provider $20 $40 Express Care Virtual and Express Care Clinics Alternative care provider $40 $80 Specialist $40 $80 Hospital Services Inpatient hospital services and maternity care 20% 30% Emergency Emergency services (all emergency services are treated as in-network) Urgent Care Urgent care services (urgent care covered out-ofnetwork, deductible applies) Outpatient Diagnostic Services 20% 30% $60 $70 X-ray and lab services 20% 30% High-tech imaging services (such as PET, CT, MRI) 20% 30% Mental Health and Chemical Dependency Inpatient and residential services 20% 30% Outpatient provider visits $20 $40 Other Covered Services Outpatient surgery at an ambulatory surgery center or hospital-based facility 20% 30% Chiropractic manipulation and acupuncture Not covered Not covered Not covered Prescription Drugs Preferred generic $10 $15 Non-preferred generic $10 $15 Preferred brand name $30 $60 Non-preferred brand name 50% 50% Preferred specialty 50% with a $500 per script cap 50% Non-preferred specialty 50% with a $500 per script cap 50% Pediatric Vision Services (children 18 years and younger) Routine eye exams (one exam per calendar year) Vision hardware (frames, lenses, contact lenses) limits apply Adult Vision Services Routine eye exams (one exam per calendar year) Not covered Not covered Not covered Vision hardware (frames, lenses, contact lenses) Not covered Not covered Not covered Pediatric Dental Services* (children 18 years and younger) Preventive services (includes routine exams, cleanings, bitewing X-rays, topical fluoride) Not covered Not covered Not covered Basic services (restorative fillings) Not covered Not covered Not covered Major services (includes oral surgery, crowns, periodontics, endodontics, denture and bridge work) Not covered Not covered Not covered Deductible is waived for these services. Please visit ProvidenceHealthPlan.com/shop to compare plans, see rates and enroll.

6 HSA Qualified This high-deductible plan provides affordable coverage with a lower premium. With an HSA Qualified plan, paired with a tax-exempt health savings account, you save pre-tax dollars to pay for future health care expenses. The HSA Qualified plan offers: A preferred rate on a health savings account with HealthEquity, a partner of Providence Health Plan Lower premiums with most services subject to the deductible No out-of-network benefits are included with this plan. You must use an in-network provider to receive benefits except for emergency and urgent care services Emergency and urgent care services covered in- and out-of-network In some counties, your provider network is the Providence Choice Network. In other counties, your provider network is the Providence Signature Network Access to specialists via referral from the medical home on the Choice Network. No referral needed for the Signature Network The option to add dental coverage with the Providence Progressive Dental Plan, as long as you buy a medical plan directly from PHP or a producer. Providence Progressive Dental is not available through Healthcare.gov HSA Qualified HSA Qualified 6650 Bronze Annual Deductible $6,650/$13,300 Individual/family Annual Out-of-Pocket Maximum $6,650/$13,300 Individual/family After meeting your deductible, you pay the following amounts for covered services. The deductible does not apply to some covered services. These are marked with. Preventive Care Periodic health exams and well-baby care (from any provider licensed to perform the service) Maternity prenatal office visits Annual gynecological exam and Pap test Mammograms Colorectal cancer screenings (preventive age 50 and over) Providence Choice Network: A network of nearly 300 primary care clinics designated as medical homes Providence Signature Network: A nationwide network of nearly 1 million providers, both in Providence facilities and in other locations Coos Curry Lincoln Clatsop Tillamook Yamhill Polk Benton Douglas Columbia Marion Linn Lane Jackson Washington Multnomah Clackamas Klamath Choice Network Wasco Jefferson Sherman Crook Umatilla Union For a listing of our Choice or Signature Network providers, visit ProvidenceHealthPlan.com/findaprovider. For more information about Providence medical homes, visit ProvidenceHealthPlan.com/medhome. Gilliiam Wheeler Lake Morrow Grant Harney Baker Signature Network Wallowa Malheur HSA Qualified (continued) Office Visits for Medical Services Personal physician/provider Express Care Virtual and Express Care Clinics Alternative care provider Specialist Hospital Services Inpatient hospital services and maternity care Emergency Emergency services (all emergency services are treated as in-network) Urgent Care Urgent care services (urgent care covered out-of-network, deductible applies) Outpatient Diagnostic Services X-ray and lab services High-tech imaging services (such as PET, CT, MRI) Mental Health and Chemical Dependency Inpatient and residential services Outpatient provider visits Other Covered Services Outpatient surgery at an ambulatory surgery center or hospital-based facility Chiropractic manipulation and acupuncture Prescription Drugs Preferred generic Non-preferred generic Preferred brand name Non-preferred brand name Preferred specialty Non-preferred specialty Pediatric Vision Services (children 18 years and younger) Routine eye exams (one exam per calendar year) Vision hardware (frames, lenses, contact lenses) limits apply Adult Vision Services Routine eye exams (one exam per calendar year) Vision hardware (frames, lenses, contact lenses) Pediatric Dental Services* (children 18 years and younger) Preventive services (includes routine exams, cleanings, bitewing X-rays, topical fluoride) Basic services (restorative fillings) Major services (includes oral surgery, crowns, periodontics, endodontics, denture and bridge work) Deductible is waived for these services. *Dental services subject to medical deductible and out-of-pocket maximum. Please visit ProvidenceHealthPlan.com/shop to compare plans, see rates and enroll. HSA Qualified 6650 Bronze Not covered Covered Covered Not covered Not covered Not covered Not covered Not covered

7 Providence Progressive Dental Plan option Providence Progressive Dental provides comprehensive benefits that promote good health with coverage for preventive care, such as X-rays and cleanings. Basic and major services, including extractions, crowns and dentures, are also covered. Through the plan, you have access to more than 2,300 in-network dental provider listings in Oregon and southwest Washington and more than 270,000 in-network provider listings nationwide. To search for a dentist, visit ProvidenceHealthPlan.com/findaprovider. Providence Progressive Dental Plan features: Progressive benefits reward proper dental care by reducing your costs in subsequent years of service There is no out-of-network coverage, so you must use an in-network provider to receive benefits There are no waiting periods for dental coverage diagnostic and preventive care services, such as exams, cleanings and X-rays, are covered in full. You are also covered for more extensive services, including root canals, crowns, bridges and dentures. Rate: $32 per member per month Other things to know as you consider your coverage. Special enrollment To apply for 2019 medical coverage or make a change to your current plan outside of the open enrollment period, you must qualify for special enrollment. You can apply for and get health insurance coverage during the special enrollment period if you experience an involuntary loss of minimum essential coverage except for failure to pay the premium or experience certain life events, such as marriage or adoption. For more information and a list of qualifying events, visit ProvidenceHealthPlan.com/qe. Eligibility To purchase one of our plans, you must live in the plan selling area and reside in the state of Oregon. In order to be eligible to enroll in the Providence Progressive Dental Plan, you must enroll in a Providence Health Plan Individual and Family medical plan. Providence is non-duplication with Medicare on Individual and Family plans. Someone who is entitled to Medicare part A or enrolled in part B is not eligible to enroll in a Providence Health Plan Individual and Family plan. Providence Progressive Dental Plan Deductible (per person) $25 Deductible (per family) $75 Annual maximum benefit (per person)* $1000 Waiting period Below is the amount you pay after you have met your deductible. The deductible is waived for some covered services. These are marked with. Diagnostic & preventive services (includes routine exams, bitewing X-rays, cleanings, topical fluoride (age 16 and younger)) None Year 1 Year 2 Year 3 Covered in full Covered in full Covered in full Basic services (includes restorative fillings) 50% 40% 20% Major services (includes oral surgery, crowns, endodontics, periodontics, denture and bridge work) *Preventive services do not apply to the annual maximum benefit. Important information about dental coverage: 75% 65% 50% You must purchase a PHP medical plan in order to purchase the Providence Progressive Dental Plan. You may not purchase our dental plan if you get your Providence medical plan through the Marketplace. If you apply for this dental plan, everyone on the application will be included on the dental plan. If anyone in your family wishes to have just medical and not dental, you must submit a separate application. Our optional Providence Progressive Dental Plan provides benefits for adults and children for an additional monthly premium per person, per month. If you choose Providence Progressive Dental, all people listed on the application will be enrolled and charged the dental premium amount in addition to the medical plan premium. 12 Visit ProvidenceHealthPlan.com to learn about Providence Health Plan privacy practices. You may obtain 13 If you purchase a Providence Health Plan Standard or HSA Qualified medical plan, adding the Providence Progressive Dental Plan for children aged 18 and younger does not satisfy the ACA pediatric dental Essential Health Benefit (EHB) requirement. For more details on the Providence Progressive Dental Plan, visit ProvidenceHealthPlan.com. Application and initial premium payment dates Your application must be submitted directly to Providence Health Plan. Visit ProvidenceHealthPlan.com/shop to use our online shopping and enrollment tool. At the time you submit your online application, you will be directed to make your initial premium payment. The Effective Date of Coverage is determined by the Qualifying Event as well as Providence Health Plan s receipt of the initial Premium. Date application is received Coverage effective date 1 st to 15 th of the month 1 st day of the following month 16 th to last day of the month 1 st day of the 2 nd following month For example: If your application is received on April 14, then your coverage starts May 1. If your application is received on April 18, then your coverage starts June 1. Monthly premium payment information After you have been enrolled, your monthly premium payment is due on the first of each month. Providence Health Plan encourages you to visit Providence.org/premiumpay to set up a recurring payment arrangement through the Providence Health Plan electronic payment system. Please note: Providence Health Plan does not accept any premium payments made by an employer or a third party except as permitted by state or federal regulation. Key health insurance terms See our online Glossary at ProvidenceHealthPlan.com/glossary for an explanations and definitions of health insurance terms. Privacy policy a copy of our Providence Health Plan Notice of Privacy Practices by going to ProvidenceHealthPlan.com and selecting Privacy Notices & Policies or by calling customer service at

8 Our Mission As expressions of God s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable. Our Values Compassion Dignity Justice Excellence Integrity Portland metro area All other areas Hours: 8 a.m. to 5 p.m., Monday Friday (Pacific Time) ProvidenceHealthPlan.com Providence Health & Services, a not-for-profit health system, is an equal opportunity organization in the provision of health care services and employment opportunities Providence Health Plan. All rights reserved. IND-063B (09/18) PHP18-123

9 Providence Health Plan 2019 Individual & Family Plan Rates Plan availability varies by county. To determine the premium for you and your family, go to the section below for the county in which you live and choose the plan that fits your needs. Then use the ages for each person to be covered to determine the rate. Please note that if any person aged 21 and older is a tobacco, you will need to use the rates for that person. Add the premium amounts for each family member to determine your total. If you re covering more than three children 20 years of age and younger, only add the premiums for your first three children. Counties c OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network Connect 2500 Silver Connect 7900 Bronze OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network Connect 2500 Silver Connect 7900 Bronze OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network Clackamas, Multnomah, Washington and Yamhill (Connect plans include only zip code in Yamhill county) Clackamas, Multnomah, Washington and Yamhill (Connect plans include only zip code in Yamhill county) Clackamas, Multnomah, Washington and Yamhill (Connect plans include only zip code in Yamhill county) Clackamas, Multnomah, Washington and Yamhill (Connect plans include only zip code in Yamhill county) * * OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network Connect 2500 Silver Connect 7900 Bronze OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network Connect 2500 Silver Connect 7900 Bronze OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network Benton, Lane, Linn Benton, Lane, Linn OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network Benton, Lane, Linn * OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network

10 Benton, Lane, Linn * OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network Marion, Polk Marion, Polk OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network Marion, Polk Marion, Polk * * OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network Klamath, Lake Klamath, Lake OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Signature Network OR Standard Silver Plan-Signature Network OR Standard Bronze Plan-Signature Network (not HSA Qualified) HSA Qualified 6650 Bronze - Signature Network OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Signature Network OR Standard Silver Plan-Signature Network OR Standard Bronze Plan-Signature Network (not HSA Qualified) HSA Qualified 6650 Bronze - Signature Network Klamath Lake * OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Signature Network OR Standard Silver Plan-Signature Network

11 Klamath, Lake Klamath, Lake * OR Standard Bronze Plan-Signature Network (not HSA Qualified) HSA Qualified 6650 Bronze - Signature Network OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Signature Network OR Standard Silver Plan-Signature Network OR Standard Bronze Plan-Signature Network (not HSA Qualified) HSA Qualified 6650 Bronze - Signature Network Clatsop, Lincoln Columbia, Coos, Curry, Tillamook Clatsop, Lincoln Columbia, Coos, Curry, Tillamook OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Signature Network OR Standard Silver Plan-Signature Network OR Standard Bronze Plan-Signature Network (not HSA Qualified) HSA Qualified 6650 Bronze - Signature Network OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Signature Network OR Standard Silver Plan-Signature Network OR Standard Bronze Plan-Signature Network (not HSA Qualified) HSA Qualified 6650 Bronze - Signature Network Clatsop, Lincoln Columbia, Coos, Curry, Tillamook Clatsop, Lincoln Columbia, Coos, Curry, Tillamook * * OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Signature Network OR Standard Silver Plan-Signature Network OR Standard Bronze Plan-Signature Network (not HSA Qualified) HSA Qualified 6650 Bronze - Signature Network OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Signature Network OR Standard Silver Plan-Signature Network OR Standard Bronze Plan-Signature Network (not HSA Qualified) HSA Qualified 6650 Bronze - Signature Network Crook Jefferson OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network

12 Crook,, Jefferson Baker, Gilliam, Grant, Harney, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, Wasco, Wheeler Crook,, Jefferson Baker, Gilliam, Grant, Harney, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, Wasco, Wheeler OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Signature Network OR Standard Silver Plan-Signature Network OR Standard Bronze Plan-Signature Network (not HSA Qualified) HSA Qualified 6650 Bronze - Signature Network Connect 2500 Silver Connect 7900 Bronze OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Signature Network OR Standard Silver Plan-Signature Network OR Standard Bronze Plan-Signature Network (not HSA Qualified) HSA Qualified 6650 Bronze - Signature Network Connect 2500 Silver Connect 7900 Bronze Crook,, Jefferson Baker, Gilliam, Grant, Harney, Malheur, Morrow, Sherma, Umatilla, Union, Wallowa, Wasco, Wheeler Crook,, Jefferson Baker, Gilliam, Grant, Harney, Malheur, Morrow, Sherma, Umatilla, Union, Wallowa, Wasco, Wheeler * * OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Signature Network OR Standard Silver Plan-Signature Network OR Standard Bronze Plan-Signature Network (not HSA Qualified) HSA Qualified 6650 Bronze - Signature Network Connect 2500 Silver Connect 7900 Bronze OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Signature Network OR Standard Silver Plan-Signature Network OR Standard Bronze Plan-Signature Network (not HSA Qualified) HSA Qualified 6650 Bronze - Signature Network Connect 2500 Silver Connect 7900 Bronze Douglas, Jackson OR Standard Gold Plan -Choice Network OR Standard Silver Plan-Choice Network OR Standard Bronze Plan-Choice Network (not HSA Qualified) HSA Qualified 6650 Bronze - Choice Network OR Standard Gold Plan -Signature Network OR Standard Silver Plan-Signature Network OR Standard Bronze Plan-Signature Network (not HSA Qualified) HSA Qualified 6650 Bronze - Signature Network OR Standard Gold Plan -Choice Network