MSC 0080 (08/15)
Information MemorandumTransmittal Aging and People with Disabilities
Kevin Nygren
Number: APD-IM-16-114 Authorized signature Issue date: 12/22/2016 Topic: Other Subject: Oregon's 2017 Medicare Advantage Plans Applies to (check all that apply):
All DHS employees County Mental Health Directors Area Agencies on Aging Health Services Aging and People with Disabilities Office of Developmental
Disabilities Services(ODDS) Self Sufficiency Programs County DD Program Managers ODDS Children’s Intensive
In Home Services ODDS Children’s Residential Services
Stabilization and Crisis Unit (SACU)
Child Welfare Programs Other (please specify): Message: Recently, the Centers for Medicare and Medicaid Services (CMS) announced the 2017 Medicare Advantage and Medicare Advantage Prescription Drug Plans (MA-PDs). MA plans are offered by a private company that contracts with Medicare to provide beneficiaries with all their Medicare Part B benefits. MA-PD plans are Medicare Advantage plans that offer Medicare Prescription Drug coverage along with Part A and Part B benefits in one plan. Medicare Advantage Plans are HMOs, PPOs, or Private Fee-for-Service Plans. When a client is enrolled in a Medicare Advantage Plan the Medicare services are paid through the plans, and are not paid through Original Medicare. The 1st attached document is the CCO and Affiliated Medicare Advantage list. The 2nd attached document is the Medicare Advantage Health Plan enrollment contact list.
MSC 0080 (08/15)
The 3rd attached document is the “2017 MA-PDs” plan list. The MA-PDs are alphabetically arranged by county. MA-PDs Special Needs Plans (SNP) are highlighted in yellow.
If you have any questions about this information, contact: Contact(s): Kesha Baxter
Phone: 503-945-6082 Fax: Email: [email protected]
12/20/2016
Coordinated Care (CCO) Affiliated
Plan
Medicare Advantage Plan
Name
Medicare Advantage Plan Service Area
AllCare Health Plan CareSource Josephine Jackson Douglas (partial)
Cascade Health Alliance
ATRIO Health Plans
Klamath-all zip codes served except 97731, 97733,97737 & 97739
Columbia Pacific CareOregon Advantage
Clatsop, Columbia, Coos-97449; Tillamook
Eastern Oregon CCO Moda Health MO Baker, Gilliam, Grant, Harney, Lake, Malheur, Morrow Sherman, Umatilla, Union, Wallowa, Wheeler
FamilyCare FamilyCare MA Plan
Clackamas, Multnomah, Washington
Health Share
Care Oregon Adv. Providence Adv. Kaiser Senior Adv.
Clackamas, Multnomah, Washington
Intercommunity Health Network (IHN)
Samaritan Advantage
Benton, Lincoln, Linn
Jackson Care Connect
CareOregon Jackson
PacificSource Central Oregon
PacificSource MA Crook, Deschutes, Jefferson; Klamath-97731,97733, 97337 & 97339
PacificSource George PacificSource MA Hood River, Wasco Primary Health of Josephine County
ATRIO Health Plans
Josephine
Trillium Trillium MA Plans Lane
Umpqua ATRIO Health Plans
Douglas-all zip codes served except 97441,97467 & 97473
12/20/2016
Western Oregon Advanced Health (WOAH)
N/A None at this time
Willamette Valley Community Health (WVCH0
ATRIO Health Plan Benton-97361 Clackamas-97002,97032,97071,97362 & 97375 Linn-97346,97350,97352,97358,97360 & 97383 Marion Polk Yamhill-97304
Yamhill County CCO (YCCO)
CareOregon Advantage
Yamhill
12/22/2016 1
Medicare Advantage Health Plan Enrollment Contacts
Atrio Health Plans Phone: 541-672-8620, ask for the Enrollment Department
Fax or mail 7208M form to:
Fax: 541-672-7870
Mailing address
2270 N.W. Aviation Suite 3 Roseburg OR, 97470
CareOregon Advantage: Enrollment Department Phone: 503-416-4279
Fax form to:
Fax: 503-416-8117
CareSource Contact: Marketing Department
Phone: 888-460-0185
Fax, mail or e-mail 7208M form to:
Fax: 541-471-3784
12/22/2016 2
Mailing Address
740 SE 7TH St.
Grants Pass OR, 97526
www.Caresourcehealthplan.com . Family Care, Inc. Plan contacts:
Mark Weinsoft
Phone: 503 734-3110
Amber Kelsoell
503-488-3747
Fax or e-mail 7208M form to:
Fax: 503-345-5751
E-mail: [email protected]
Kaiser Permanente Senior Advantage Plan Contact: Danny Covarrubio
Phone: 1-858-614-3433
Fax form to:
Fax: 1-866-551-9598
12/22/2016 3
MODA Health Plan Inc. Contact: Billing and Eligibility
Phone: 503-382-5357 or 1-866-940-0357
Fax, mail or e-mail 7208M form to:
Fax: 503-224-1975
Mailing address:
MODA Health Plan
601 S.W. 2nd Ave
Portland OR, 97204
E-mail: [email protected]
Pacific Source
Contact: Bob Smith
Phone: 541-330-7325
Fax, mail or e-mail 7208M form to:
Fax: 855-382-4217
Mailing address
Pacific Source
P.O. Box 7469
12/22/2016 4
Bend OR, 97708
Medicare applications can also be sent to
[email protected] via secure email
Providence Health Plan Contact: Sharena Kent
Phone: 503-574-7527
Fax or mail 7208M form to:
Fax: 503-574-8607
Mailing address:
Providence Health Plan
P.O. Box 5548
Portland OR, 97228
Samaritan Advantage Health Plan Brenda Page
541-768-4487
Samaritan Advantage Enrollment line
1-800-832-4580
Fax or mail 7208M form to:
Fax: 541-768-9778 (Attention: Enrollment Department)
12/22/2016 5
Mailing address:
Samaritan Advantage Health Plan
P.O. Box M
Corvallis OR, 97339
Trillium Contact: Billie Stoltz
E-mail: [email protected]
Phone: 541-431-1950 x 1283
Fax or mail 7208M form to:
Fax: 541-984-5690
Trillium Health Plan
P.O. Box 11756
Eugene OR, 97440
Regence
Contact: Government Programs (Customer Service)
Phone: 1-800-541-8981
Fax or mail 7208M form to:
Fax: 1-888-335-2988
12/22/2016 6
Mailing Address:
P.O. Box 12685
Salem OR, 97309
***Enrollment and dis-enrollment decisions must be documented using the
7208M and 7209 forms and sent to the MA plan
1
County Organization
Name Plan Name Contract
ID Plan ID Plan Type
Special Needs Plan
Special Needs
Plan Type Benefit Type
Part C Premium
2
Part D Basic
Premium3
Part D Premium
Obligation with Full Premium
Assistance
Baker Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Baker Moda Health Plan, Inc.
Moda Health HMO (HMO-POS) H8506 001 HMOPOS No
Enhanced Alternative $0.00 $63.00 $28.20
Benton UnitedHealthcare
AARP MedicareComplete Plan 1 (HMO) H3805 007 HMO No
Enhanced Alternative $24.80 $21.20 $0.00
Benton UnitedHealthcare
AARP MedicareComplete Plan 2 (HMO) H3805 013 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Benton
Samaritan Advantage Health Plan
Samaritan Advantage Premier Plan (HMO) H3811 002 HMO No
Enhanced Alternative $56.60 $53.40 $18.60
Benton
Samaritan Advantage Health Plan
Samaritan Advantage Premier Plan Plus (HMO) H3811 009 HMO No
Enhanced Alternative $70.90 $69.10 $34.30
Benton Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Benton
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO) H3817 008
Local PPO No
Basic Alternative $51.50 $49.50 $14.70
Benton
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO) H3817 009
Local PPO No
Enhanced Alternative $147.40 $66.90 $55.80
Benton Health Net Life Insurance Company
Health Net Violet Option 1 (PPO) H5520 002
Local PPO No
Enhanced Alternative $76.30 $39.70 $4.90
Benton Health Net Life Insurance Company
Health Net Violet Option 2 (PPO) H5520 012
Local PPO No
Basic Alternative $0.00 $24.00 $0.00
2
Benton Humana Insurance Company
HumanaChoice H6609-073 (PPO) H6609 073
Local PPO No
Basic Alternative $168.90 $32.10 $0.00
Benton Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO) H6815 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Benton Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO) H9003 001 HMO No
Enhanced Alternative $61.00 $41.50 $31.20
Benton Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO) H9003 006 HMO No
Enhanced Alternative $14.70 $29.30 $0.00
Benton UnitedHealthcare
UnitedHealthcare Nursing Home Plan (PPO SNP) H2228 016
Local PPO Yes Institutional
Defined Standard Benefit $0.00 $28.70 $0.00
Benton UnitedHealthcare
UnitedHealthcare Assisted Living Plan (PPO SNP) H2228 017
Local PPO Yes Institutional
Basic Alternative $0.00 $24.90 $0.00
Benton
Samaritan Advantage Health Plan
Samaritan Advantage Special Needs Plan (HMO SNP) H3811 003 HMO Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Benton Health Net Health Plan of Oregon, Inc.
Health Net Jade (HMO SNP) H6815 004 HMO Yes
Chronic or Disabling Condition
Enhanced Alternative $0.00 $0.00 $0.00
Clackamas Humana Medical Plan, Inc.
Humana Gold Plus H1036-153 (HMO) H1036 153 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Clackamas UnitedHealthcare
AARP MedicareComplete Choice (PPO) H2228 029
Local PPO No
Enhanced Alternative $2.50 $29.50 $0.00
Clackamas UnitedHealthcare
AARP MedicareComplete Plan 1 (HMO) H3805 001 HMO No
Enhanced Alternative $40.50 $26.50 $0.00
Clackamas UnitedHealthcare
AARP MedicareComplete Plan 2 (HMO) H3805 012 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
3
Clackamas Providence ElderPlace Portland
Providence ElderPlace Portland (dual eligible) (PACE) H3809 001
National PACE No $161.70 $0.00
Clackamas Providence ElderPlace Portland
Providence ElderPlace Portland (private pay) (PACE) H3809 002
National PACE No $125.50 $498.80
Clackamas Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Clackamas
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO) H3817 008
Local PPO No
Basic Alternative $2.00 $41.00 $6.20
Clackamas
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO) H3817 009
Local PPO No
Enhanced Alternative $106.40 $66.90 $55.80
Clackamas FamilyCare Health
FamilyCare Advantage Rx (HMO) H3818 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Clackamas PacificSource Medicare
PacificSource Medicare MyCare Rx 22 (HMO) H3864 022 HMO No
Enhanced Alternative $48.80 $29.20 $0.00
Clackamas Health Net Life Insurance Company
Health Net Violet Option 1 (PPO) H5520 002
Local PPO No
Enhanced Alternative $76.30 $39.70 $4.90
Clackamas Health Net Life Insurance Company
Health Net Violet Option 2 (PPO) H5520 012
Local PPO No
Basic Alternative $0.00 $19.00 $0.00
Clackamas CareOregon Advantage
CareOregon Advantage Star (HMO-POS) H5859 003 HMOPOS No
Enhanced Alternative $0.00 $34.80 $0.00
Clackamas
Regence BlueCross BlueShield of Oregon
Regence BlueAdvantage HMO (HMO) H6237 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Clackamas Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO) H6815 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
4
Clackamas Humana Insurance Company
Humana Gold Choice H8145-093 (PFFS) H8145 093 PFFS No
Enhanced Alternative $47.60 $34.90 $4.60
Clackamas Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO) H9003 001 HMO No
Enhanced Alternative $61.00 $41.50 $31.20
Clackamas Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO) H9003 006 HMO No
Enhanced Alternative $14.70 $29.30 $0.00
Clackamas Providence Health Assurance
Providence Medicare Extra + RX (HMO) H9047 001 HMO No
Enhanced Alternative $109.10 $52.50 $18.10
Clackamas Providence Health Assurance
Providence Medicare Extra Part B Only + RX (HMO) H9047 013 HMO No
Enhanced Alternative $375.60 $42.10 $7.30
Clackamas Providence Health Assurance
Providence Medicare Choice + RX (HMO-POS) H9047 024 HMOPOS No
Enhanced Alternative $39.50 $48.50 $13.70
Clackamas Providence Health Assurance
Providence Medicare Prime + RX (HMO-POS) H9047 037 HMOPOS No
Enhanced Alternative $0.00 $0.00 $0.00
Clackamas
AgeRight Advantage Health Plan (HMO SNP)
AgeRight Advantage Health Plan (HMO SNP) (HMO SNP) H1372 001 HMO Yes Institutional
Defined Standard Benefit $0.00 $30.40 $0.00
Clackamas UnitedHealthcare
UnitedHealthcare Nursing Home Plan (PPO SNP) H2228 016
Local PPO Yes Institutional
Defined Standard Benefit $0.00 $28.70 $0.00
Clackamas UnitedHealthcare
UnitedHealthcare Assisted Living Plan (PPO SNP) H2228 017
Local PPO Yes Institutional
Basic Alternative $0.00 $24.90 $0.00
5
Clackamas FamilyCare Health
FamilyCare Community (HMO SNP) H3818 002 HMO Yes
Dual-Eligible
Enhanced Alternative $0.00 $31.40 $0.00
Clackamas CareOregon Advantage
CareOregon Advantage Plus (HMO-POS SNP) H5859 001 HMOPOS Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Clackamas Health Net Health Plan of Oregon, Inc.
Health Net Jade (HMO SNP) H6815 004 HMO Yes
Chronic or Disabling Condition
Enhanced Alternative $0.00 $0.00 $0.00
Clackamas Providence Health Assurance
Providence Medicare Dual Plus (HMO SNP) H9047 043 HMO Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Clatsop Providence ElderPlace Portland
Providence ElderPlace Portland (dual eligible) (PACE) H3809 001
National PACE No $161.70 $0.00
Clatsop Providence ElderPlace Portland
Providence ElderPlace Portland (private pay) (PACE) H3809 002
National PACE No $125.50 $498.80
Clatsop Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Clatsop FamilyCare Health
FamilyCare Advantage Rx (HMO) H3818 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Clatsop CareOregon Advantage
CareOregon Advantage Star (HMO-POS) H5859 003 HMOPOS No
Enhanced Alternative $0.00 $34.80 $0.00
Clatsop FamilyCare Health
FamilyCare Community (HMO SNP) H3818 002 HMO Yes
Dual-Eligible
Enhanced Alternative $0.00 $31.40 $0.00
Clatsop CareOregon Advantage
CareOregon Advantage Plus (HMO-POS SNP) H5859 001 HMOPOS Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
6
Columbia Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Columbia
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO) H3817 008
Local PPO No
Basic Alternative $51.50 $49.50 $14.70
Columbia
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO) H3817 009
Local PPO No
Enhanced Alternative $147.40 $66.90 $55.80
Columbia CareOregon Advantage
CareOregon Advantage Star (HMO-POS) H5859 003 HMOPOS No
Enhanced Alternative $0.00 $34.80 $0.00
Columbia Humana Insurance Company
HumanaChoice H6609-073 (PPO) H6609 073
Local PPO No
Basic Alternative $168.90 $32.10 $0.00
Columbia Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO) H9003 001 HMO No
Enhanced Alternative $61.00 $41.50 $31.20
Columbia Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO) H9003 006 HMO No
Enhanced Alternative $14.70 $29.30 $0.00
Columbia Providence Health Assurance
Providence Medicare Extra + RX (HMO) H9047 001 HMO No
Enhanced Alternative $109.10 $52.50 $18.10
Columbia Providence Health Assurance
Providence Medicare Extra Part B Only + RX (HMO) H9047 013 HMO No
Enhanced Alternative $375.60 $42.10 $7.30
Columbia Providence Health Assurance
Providence Medicare Choice + RX (HMO-POS) H9047 024 HMOPOS No
Enhanced Alternative $39.50 $48.50 $13.70
Columbia CareOregon Advantage
CareOregon Advantage Plus (HMO-POS SNP) H5859 001 HMOPOS Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Coos Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
7
Coos
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO) H3817 008
Local PPO No
Basic Alternative $51.50 $49.50 $14.70
Coos
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO) H3817 009
Local PPO No
Enhanced Alternative $147.40 $66.90 $55.80
Coos PacificSource Medicare
PacificSource Medicare Essentials Rx 26 (HMO) H3864 026 HMO No
Enhanced Alternative $55.00 $31.00 $0.00
Coos PacificSource Medicare
PacificSource Medicare Explorer Rx 7 (PPO) H4754 007
Local PPO No
Enhanced Alternative $74.40 $29.60 $16.00
Crook Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Crook PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO) H3864 006 HMO No
Enhanced Alternative $134.80 $50.30 $35.40
Crook PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) H3864 014 HMOPOS No
Enhanced Alternative $73.80 $34.00 $19.20
Crook PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO) H3864 027 HMO No
Basic Alternative $67.70 $54.30 $19.50
Crook Humana Insurance Company
HumanaChoice H6609-013 (PPO) H6609 013
Local PPO No
Enhanced Alternative $66.40 $31.50 $4.10
Crook Humana Insurance Company
HumanaChoice H6609-073 (PPO) H6609 073
Local PPO No
Basic Alternative $168.90 $32.10 $0.00
Crook Providence Health Assurance
Providence Medicare Latitude + RX (HMO-POS) H9047 038 HMOPOS No
Enhanced Alternative $111.60 $46.40 $22.60
8
Crook Providence Health Assurance
Providence Medicare Compass + RX (HMO-POS) H9047 039 HMOPOS No
Enhanced Alternative $59.70 $39.30 $4.50
Curry Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Curry
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO) H3817 008
Local PPO No
Basic Alternative $51.50 $49.50 $14.70
Curry
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO) H3817 009
Local PPO No
Enhanced Alternative $147.40 $66.90 $55.80
Curry PacificSource Medicare
PacificSource Medicare Essentials Rx 26 (HMO) H3864 026 HMO No
Enhanced Alternative $55.00 $31.00 $0.00
Curry PacificSource Medicare
PacificSource Medicare Explorer Rx 7 (PPO) H4754 007
Local PPO No
Enhanced Alternative $74.40 $29.60 $16.00
Deschutes Humana Medical Plan, Inc.
Humana Gold Plus H1036-219 (HMO) H1036 219 HMO No
Enhanced Alternative $47.60 $16.10 $7.30
Deschutes Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Deschutes PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO) H3864 006 HMO No
Enhanced Alternative $134.80 $50.30 $35.40
Deschutes PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) H3864 014 HMOPOS No
Enhanced Alternative $73.80 $34.00 $19.20
Deschutes PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO) H3864 027 HMO No
Basic Alternative $67.70 $54.30 $19.50
9
Deschutes Humana Insurance Company
HumanaChoice H6609-013 (PPO) H6609 013
Local PPO No
Enhanced Alternative $66.40 $31.50 $4.10
Deschutes Humana Insurance Company
HumanaChoice H6609-073 (PPO) H6609 073
Local PPO No
Basic Alternative $168.90 $32.10 $0.00
Deschutes Providence Health Assurance
Providence Medicare Latitude + RX (HMO-POS) H9047 038 HMOPOS No
Enhanced Alternative $111.60 $46.40 $22.60
Deschutes Providence Health Assurance
Providence Medicare Compass + RX (HMO-POS) H9047 039 HMOPOS No
Enhanced Alternative $59.70 $39.30 $4.50
Douglas AllCare Advantage
AllCare Advantage Gold Plus Rx (HMO) H3810 003 HMO No
Enhanced Alternative $90.60 $50.90 $16.10
Douglas Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Douglas
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO) H3817 008
Local PPO No
Basic Alternative $51.50 $49.50 $14.70
Douglas
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO) H3817 009
Local PPO No
Enhanced Alternative $147.40 $66.90 $55.80
Douglas Health Net Life Insurance Company
Health Net Violet Option 1 (PPO) H5520 004
Local PPO No
Enhanced Alternative $71.10 $33.90 $0.00
Douglas Health Net Life Insurance Company
Health Net Violet Option 3 (PPO) H5520 014
Local PPO No
Enhanced Alternative $0.00 $0.00 $0.00
Douglas Health Net Life Insurance Company
Health Net Violet Option 2 (PPO) H5520 015
Local PPO No
Basic Alternative $0.00 $25.00 $0.00
Douglas ATRIO Health Plans
ATRIO Silver Rx (PPO) H6743 003
Local PPO No
Enhanced Alternative $80.40 $32.60 $0.00
Douglas ATRIO Health Plans
ATRIO Gold Rx (PPO) H6743 004
Local PPO No
Enhanced Alternative $132.60 $32.60 $14.80
Douglas ATRIO Health Plans
ATRIO Bronze Rx (Umpqua) (PPO) H6743 007
Local PPO No
Enhanced Alternative $0.00 $0.00 $0.00
10
Douglas ATRIO Health Plans
ATRIO Special Needs Plan (HMO SNP) H3814 007 HMO Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Gilliam Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Gilliam Moda Health Plan, Inc.
Moda Health HMO (HMO-POS) H8506 001 HMOPOS No
Enhanced Alternative $0.00 $63.00 $28.20
Grant Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Grant PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO) H3864 006 HMO No
Enhanced Alternative $134.80 $50.30 $35.40
Grant PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) H3864 014 HMOPOS No
Enhanced Alternative $73.80 $34.00 $19.20
Grant PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO) H3864 027 HMO No
Basic Alternative $67.70 $54.30 $19.50
Grant Moda Health Plan, Inc.
Moda Health HMO (HMO-POS) H8506 001 HMOPOS No
Enhanced Alternative $0.00 $63.00 $28.20
Harney Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Harney Moda Health Plan, Inc.
Moda Health HMO (HMO-POS) H8506 001 HMOPOS No
Enhanced Alternative $0.00 $63.00 $28.20
Hood River Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Hood River PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO) H3864 006 HMO No
Enhanced Alternative $134.80 $50.30 $35.40
11
Hood River PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) H3864 014 HMOPOS No
Enhanced Alternative $73.80 $34.00 $19.20
Hood River PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO) H3864 027 HMO No
Basic Alternative $67.70 $54.30 $19.50
Hood River Humana Insurance Company
HumanaChoice H6609-073 (PPO) H6609 073
Local PPO No
Basic Alternative $168.90 $32.10 $0.00
Hood River Providence Health Assurance
Providence Medicare Latitude + RX (HMO-POS) H9047 038 HMOPOS No
Enhanced Alternative $111.60 $46.40 $22.60
Hood River Providence Health Assurance
Providence Medicare Compass + RX (HMO-POS) H9047 039 HMOPOS No
Enhanced Alternative $59.70 $39.30 $4.50
Jackson AllCare Advantage
AllCare Advantage Gold Plus Rx (HMO) H3810 003 HMO No
Enhanced Alternative $90.60 $50.90 $16.10
Jackson Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Jackson
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO) H3817 008
Local PPO No
Basic Alternative $51.50 $49.50 $14.70
Jackson
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO) H3817 009
Local PPO No
Enhanced Alternative $147.40 $66.90 $55.80
Jackson Health Net Life Insurance Company
Health Net Violet Option 1 (PPO) H5520 004
Local PPO No
Enhanced Alternative $71.10 $33.90 $0.00
Jackson Health Net Life Insurance Company
Health Net Violet Option 2 (PPO) H5520 015
Local PPO No
Basic Alternative $0.00 $25.00 $0.00
Jackson ATRIO Health Plans
ATRIO Bronze Rx (Rogue) (PPO) H6743 014
Local PPO No
Enhanced Alternative $0.00 $0.00 $0.00
12
Jackson ATRIO Health Plans
ATRIO Silver Rx (Rogue) (PPO) H6743 016
Local PPO No
Enhanced Alternative $67.20 $13.50 $22.30
Jackson ATRIO Health Plans
ATRIO Gold Rx (Rogue) (PPO) H6743 017
Local PPO No
Enhanced Alternative $100.50 $29.00 $35.50
Jackson ATRIO Health Plans
ATRIO Special Needs Plan (Rogue) (HMO SNP) H3814 029 HMO Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Jackson CareOregon Advantage
CareOregon Advantage Plus (HMO-POS SNP) H5859 001 HMOPOS Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Jefferson Humana Medical Plan, Inc.
Humana Gold Plus H1036-219 (HMO) H1036 219 HMO No
Enhanced Alternative $47.60 $16.10 $7.30
Jefferson Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Jefferson PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO) H3864 006 HMO No
Enhanced Alternative $134.80 $50.30 $35.40
Jefferson PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) H3864 014 HMOPOS No
Enhanced Alternative $73.80 $34.00 $19.20
Jefferson PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO) H3864 027 HMO No
Basic Alternative $67.70 $54.30 $19.50
Jefferson Humana Insurance Company
HumanaChoice H6609-013 (PPO) H6609 013
Local PPO No
Enhanced Alternative $66.40 $31.50 $4.10
Jefferson Humana Insurance Company
HumanaChoice H6609-073 (PPO) H6609 073
Local PPO No
Basic Alternative $168.90 $32.10 $0.00
Jefferson Providence Health Assurance
Providence Medicare Latitude + RX (HMO-POS) H9047 038 HMOPOS No
Enhanced Alternative $111.60 $46.40 $22.60
13
Jefferson Providence Health Assurance
Providence Medicare Compass + RX (HMO-POS) H9047 039 HMOPOS No
Enhanced Alternative $59.70 $39.30 $4.50
Josephine AllCare Advantage
AllCare Advantage Gold Plus Rx (HMO) H3810 003 HMO No
Enhanced Alternative $90.60 $50.90 $16.10
Josephine Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Josephine
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO) H3817 008
Local PPO No
Basic Alternative $51.50 $49.50 $14.70
Josephine
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO) H3817 009
Local PPO No
Enhanced Alternative $147.40 $66.90 $55.80
Josephine Health Net Life Insurance Company
Health Net Violet Option 1 (PPO) H5520 004
Local PPO No
Enhanced Alternative $71.10 $33.90 $0.00
Josephine Health Net Life Insurance Company
Health Net Violet Option 3 (PPO) H5520 014
Local PPO No
Enhanced Alternative $0.00 $0.00 $0.00
Josephine Health Net Life Insurance Company
Health Net Violet Option 2 (PPO) H5520 015
Local PPO No
Basic Alternative $0.00 $25.00 $0.00
Josephine ATRIO Health Plans
ATRIO Bronze Rx (Rogue) (PPO) H6743 014
Local PPO No
Enhanced Alternative $0.00 $0.00 $0.00
Josephine ATRIO Health Plans
ATRIO Silver Rx (Rogue) (PPO) H6743 016
Local PPO No
Enhanced Alternative $67.20 $13.50 $22.30
Josephine ATRIO Health Plans
ATRIO Gold Rx (Rogue) (PPO) H6743 017
Local PPO No
Enhanced Alternative $100.50 $29.00 $35.50
Josephine ATRIO Health Plans
ATRIO Special Needs Plan (Rogue) (HMO SNP) H3814 029 HMO Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Josephine CareOregon Advantage
CareOregon Advantage Plus (HMO-POS SNP) H5859 001 HMOPOS Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
14
Klamath Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Klamath PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO) H3864 006 HMO No
Enhanced Alternative $134.80 $50.30 $35.40
Klamath PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) H3864 014 HMOPOS No
Enhanced Alternative $73.80 $34.00 $19.20
Klamath PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO) H3864 027 HMO No
Basic Alternative $67.70 $54.30 $19.50
Klamath ATRIO Health Plans
ATRIO Bronze Rx (Basin) (PPO) H6743 001
Local PPO No
Enhanced Alternative $0.00 $21.00 $0.00
Klamath ATRIO Health Plans
ATRIO Silver Rx (PPO) H6743 003
Local PPO No
Enhanced Alternative $80.40 $32.60 $0.00
Klamath ATRIO Health Plans
ATRIO Gold Rx (PPO) H6743 004
Local PPO No
Enhanced Alternative $132.60 $32.60 $14.80
Klamath
AgeRight Advantage Health Plan (HMO SNP)
AgeRight Advantage Health Plan (HMO SNP) (HMO SNP) H1372 001 HMO Yes Institutional
Defined Standard Benefit $0.00 $30.40 $0.00
Klamath ATRIO Health Plans
ATRIO Special Needs Plan (HMO SNP) H3814 007 HMO Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Lake Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Lake PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO) H3864 006 HMO No
Enhanced Alternative $134.80 $50.30 $35.40
15
Lake PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) H3864 014 HMOPOS No
Enhanced Alternative $73.80 $34.00 $19.20
Lake PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO) H3864 027 HMO No
Basic Alternative $67.70 $54.30 $19.50
Lake Moda Health Plan, Inc.
Moda Health HMO (HMO-POS) H8506 001 HMOPOS No
Enhanced Alternative $0.00 $63.00 $28.20
Lane UnitedHealthcare
AARP MedicareComplete Choice (PPO) H2228 029
Local PPO No
Enhanced Alternative $2.50 $29.50 $0.00
Lane UnitedHealthcare
AARP MedicareComplete Plan 1 (HMO) H3805 007 HMO No
Enhanced Alternative $24.80 $21.20 $0.00
Lane UnitedHealthcare
AARP MedicareComplete Plan 2 (HMO) H3805 013 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Lane Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Lane
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO) H3817 008
Local PPO No
Basic Alternative $2.00 $41.00 $6.20
Lane
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO) H3817 009
Local PPO No
Enhanced Alternative $106.40 $66.90 $55.80
Lane PacificSource Medicare
PacificSource Medicare Essentials Rx 26 (HMO) H3864 026 HMO No
Enhanced Alternative $38.00 $31.00 $0.00
Lane PacificSource Medicare
PacificSource Medicare Explorer Rx 4 (PPO) H4754 004
Local PPO No
Enhanced Alternative $95.50 $46.50 $31.70
16
Lane Health Net Life Insurance Company
Health Net Violet Option 1 (PPO) H5520 002
Local PPO No
Enhanced Alternative $76.30 $39.70 $4.90
Lane Health Net Life Insurance Company
Health Net Violet Option 2 (PPO) H5520 012
Local PPO No
Basic Alternative $0.00 $19.00 $0.00
Lane Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO) H6815 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Lane Trillium Medicare Advantage
Trillium Advantage Pioneer Rx (PPO) H6951 002
Local PPO No
Enhanced Alternative $25.60 $64.40 $29.60
Lane Providence Health Assurance
Providence Medicare Extra + RX (HMO) H9047 001 HMO No
Enhanced Alternative $109.10 $52.50 $18.10
Lane Providence Health Assurance
Providence Medicare Extra Part B Only + RX (HMO) H9047 013 HMO No
Enhanced Alternative $375.60 $42.10 $7.30
Lane Providence Health Assurance
Providence Medicare Choice + RX (HMO-POS) H9047 024 HMOPOS No
Enhanced Alternative $39.50 $48.50 $13.70
Lane Trillium Medicare Advantage
Trillium Advantage Dual (HMO SNP) H2174 001 HMO Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Lane Trillium Medicare Advantage
Trillium Advantage TLC ISNP (HMO SNP) H2174 003 HMO Yes Institutional
Defined Standard Benefit $0.00 $34.80 $0.00
Lane Trillium Medicare Advantage
Trillium Advantage TLC Community ISNP (HMO SNP) H2174 005 HMO Yes Institutional
Defined Standard Benefit $0.00 $34.80 $0.00
Lane UnitedHealthcare
UnitedHealthcare Nursing Home Plan (PPO SNP) H2228 016
Local PPO Yes Institutional
Defined Standard Benefit $0.00 $28.70 $0.00
Lane UnitedHealthcare
UnitedHealthcare Assisted Living Plan (HMO SNP) H3113 008 HMO Yes Institutional
Basic Alternative $0.00 $34.80 $0.00
17
Lane Health Net Health Plan of Oregon, Inc.
Health Net Jade (HMO SNP) H6815 004 HMO Yes
Chronic or Disabling Condition
Enhanced Alternative $0.00 $0.00 $0.00
Lincoln
Samaritan Advantage Health Plan
Samaritan Advantage Premier Plan (HMO) H3811 002 HMO No
Enhanced Alternative $56.60 $53.40 $18.60
Lincoln
Samaritan Advantage Health Plan
Samaritan Advantage Premier Plan Plus (HMO) H3811 009 HMO No
Enhanced Alternative $70.90 $69.10 $34.30
Lincoln Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Lincoln Humana Insurance Company
HumanaChoice H6609-073 (PPO) H6609 073
Local PPO No
Basic Alternative $168.90 $32.10 $0.00
Lincoln
Samaritan Advantage Health Plan
Samaritan Advantage Special Needs Plan (HMO SNP) H3811 003 HMO Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Linn UnitedHealthcare
AARP MedicareComplete Plan 1 (HMO) H3805 007 HMO No
Enhanced Alternative $24.80 $21.20 $0.00
Linn UnitedHealthcare
AARP MedicareComplete Plan 2 (HMO) H3805 013 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Linn
Samaritan Advantage Health Plan
Samaritan Advantage Premier Plan (HMO) H3811 002 HMO No
Enhanced Alternative $56.60 $53.40 $18.60
Linn
Samaritan Advantage Health Plan
Samaritan Advantage Premier Plan Plus (HMO) H3811 009 HMO No
Enhanced Alternative $70.90 $69.10 $34.30
Linn Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Linn
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO) H3817 008
Local PPO No
Basic Alternative $51.50 $49.50 $14.70
18
Linn
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO) H3817 009
Local PPO No
Enhanced Alternative $147.40 $66.90 $55.80
Linn Health Net Life Insurance Company
Health Net Violet Option 1 (PPO) H5520 002
Local PPO No
Enhanced Alternative $76.30 $39.70 $4.90
Linn Health Net Life Insurance Company
Health Net Violet Option 2 (PPO) H5520 012
Local PPO No
Basic Alternative $0.00 $24.00 $0.00
Linn Humana Insurance Company
HumanaChoice H6609-073 (PPO) H6609 073
Local PPO No
Basic Alternative $168.90 $32.10 $0.00
Linn Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO) H6815 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Linn Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO) H9003 001 HMO No
Enhanced Alternative $61.00 $41.50 $31.20
Linn Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO) H9003 006 HMO No
Enhanced Alternative $14.70 $29.30 $0.00
Linn UnitedHealthcare
UnitedHealthcare Nursing Home Plan (PPO SNP) H2228 016
Local PPO Yes Institutional
Defined Standard Benefit $0.00 $28.70 $0.00
Linn UnitedHealthcare
UnitedHealthcare Assisted Living Plan (PPO SNP) H2228 017
Local PPO Yes Institutional
Basic Alternative $0.00 $24.90 $0.00
Linn
Samaritan Advantage Health Plan
Samaritan Advantage Special Needs Plan (HMO SNP) H3811 003 HMO Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Linn Health Net Health Plan of Oregon, Inc.
Health Net Jade (HMO SNP) H6815 004 HMO Yes
Chronic or Disabling Condition
Enhanced Alternative $0.00 $0.00 $0.00
Malheur Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Malheur Humana Insurance Company
HumanaChoice H6609-009 (PPO) H6609 009
Local PPO No
Enhanced Alternative $34.70 $15.10 $6.20
19
Malheur Humana Insurance Company
HumanaChoice H6609-073 (PPO) H6609 073
Local PPO No
Basic Alternative $168.90 $32.10 $0.00
Malheur Moda Health Plan, Inc.
Moda Health HMO (HMO-POS) H8506 001 HMOPOS No
Enhanced Alternative $0.00 $63.00 $28.20
Marion UnitedHealthcare
AARP MedicareComplete Choice (PPO) H2228 029
Local PPO No
Enhanced Alternative $2.50 $29.50 $0.00
Marion UnitedHealthcare
AARP MedicareComplete Plan 1 (HMO) H3805 001 HMO No
Enhanced Alternative $40.50 $26.50 $0.00
Marion UnitedHealthcare
AARP MedicareComplete Plan 2 (HMO) H3805 012 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Marion Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Marion
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO) H3817 008
Local PPO No
Basic Alternative $51.50 $49.50 $14.70
Marion
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO) H3817 009
Local PPO No
Enhanced Alternative $147.40 $66.90 $55.80
Marion Health Net Life Insurance Company
Health Net Violet Option 1 (PPO) H5520 002
Local PPO No
Enhanced Alternative $76.30 $39.70 $4.90
Marion Health Net Life Insurance Company
Health Net Violet Option 2 (PPO) H5520 012
Local PPO No
Basic Alternative $0.00 $32.00 $0.00
Marion
Regence BlueCross BlueShield of Oregon
Regence BlueAdvantage HMO (HMO) H6237 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Marion Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO) H6815 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Marion ATRIO Health Plans
ATRIO Gold Rx (Willamette) (PPO) H7006 001
Local PPO No
Enhanced Alternative $139.50 $45.50 $10.70
Marion ATRIO Health Plans
ATRIO Silver Rx (Willamette) (PPO) H7006 003
Local PPO No
Enhanced Alternative $54.10 $12.90 $0.00
20
Marion Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO) H9003 001 HMO No
Enhanced Alternative $61.00 $41.50 $31.20
Marion Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO) H9003 006 HMO No
Enhanced Alternative $14.70 $29.30 $0.00
Marion Providence Health Assurance
Providence Medicare Extra + RX (HMO) H9047 001 HMO No
Enhanced Alternative $109.10 $52.50 $18.10
Marion Providence Health Assurance
Providence Medicare Extra Part B Only + RX (HMO) H9047 013 HMO No
Enhanced Alternative $375.60 $42.10 $7.30
Marion Providence Health Assurance
Providence Medicare Choice + RX (HMO-POS) H9047 024 HMOPOS No
Enhanced Alternative $39.50 $48.50 $13.70
Marion UnitedHealthcare
UnitedHealthcare Nursing Home Plan (PPO SNP) H2228 016
Local PPO Yes Institutional
Defined Standard Benefit $0.00 $28.70 $0.00
Marion UnitedHealthcare
UnitedHealthcare Assisted Living Plan (PPO SNP) H2228 017
Local PPO Yes Institutional
Basic Alternative $0.00 $24.90 $0.00
Marion ATRIO Health Plans
ATRIO Special Needs Plan (Willamette) (HMO SNP) H5995 001 HMO Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Morrow Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Morrow Moda Health Plan, Inc.
Moda Health HMO (HMO-POS) H8506 001 HMOPOS No
Enhanced Alternative $0.00 $63.00 $28.20
Multnomah Humana Medical Plan, Inc.
Humana Gold Plus H1036-153 (HMO) H1036 153 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Multnomah UnitedHealthcare
AARP MedicareComplete Choice (PPO) H2228 029
Local PPO No
Enhanced Alternative $2.50 $29.50 $0.00
21
Multnomah UnitedHealthcare
AARP MedicareComplete Plan 1 (HMO) H3805 001 HMO No
Enhanced Alternative $40.50 $26.50 $0.00
Multnomah UnitedHealthcare
AARP MedicareComplete Plan 2 (HMO) H3805 012 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Multnomah Providence ElderPlace Portland
Providence ElderPlace Portland (dual eligible) (PACE) H3809 001
National PACE No $161.70 $0.00
Multnomah Providence ElderPlace Portland
Providence ElderPlace Portland (private pay) (PACE) H3809 002
National PACE No $125.50 $498.80
Multnomah Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Multnomah
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO) H3817 008
Local PPO No
Basic Alternative $2.00 $41.00 $6.20
Multnomah
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO) H3817 009
Local PPO No
Enhanced Alternative $106.40 $66.90 $55.80
Multnomah FamilyCare Health
FamilyCare Advantage Rx (HMO) H3818 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Multnomah PacificSource Medicare
PacificSource Medicare MyCare Rx 22 (HMO) H3864 022 HMO No
Enhanced Alternative $48.80 $29.20 $0.00
Multnomah Health Net Life Insurance Company
Health Net Violet Option 1 (PPO) H5520 002
Local PPO No
Enhanced Alternative $76.30 $39.70 $4.90
Multnomah Health Net Life Insurance Company
Health Net Violet Option 2 (PPO) H5520 012
Local PPO No
Basic Alternative $0.00 $19.00 $0.00
22
Multnomah CareOregon Advantage
CareOregon Advantage Star (HMO-POS) H5859 003 HMOPOS No
Enhanced Alternative $0.00 $34.80 $0.00
Multnomah
Regence BlueCross BlueShield of Oregon
Regence BlueAdvantage HMO (HMO) H6237 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Multnomah Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO) H6815 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Multnomah Humana Insurance Company
Humana Gold Choice H8145-093 (PFFS) H8145 093 PFFS No
Enhanced Alternative $47.60 $34.90 $4.60
Multnomah Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO) H9003 001 HMO No
Enhanced Alternative $61.00 $41.50 $31.20
Multnomah Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO) H9003 006 HMO No
Enhanced Alternative $14.70 $29.30 $0.00
Multnomah Providence Health Assurance
Providence Medicare Extra + RX (HMO) H9047 001 HMO No
Enhanced Alternative $109.10 $52.50 $18.10
Multnomah Providence Health Assurance
Providence Medicare Extra Part B Only + RX (HMO) H9047 013 HMO No
Enhanced Alternative $375.60 $42.10 $7.30
Multnomah Providence Health Assurance
Providence Medicare Choice + RX (HMO-POS) H9047 024 HMOPOS No
Enhanced Alternative $39.50 $48.50 $13.70
Multnomah Providence Health Assurance
Providence Medicare Prime + RX (HMO-POS) H9047 037 HMOPOS No
Enhanced Alternative $0.00 $0.00 $0.00
Multnomah
AgeRight Advantage Health Plan (HMO SNP)
AgeRight Advantage Health Plan (HMO SNP) (HMO SNP) H1372 001 HMO Yes Institutional
Defined Standard Benefit $0.00 $30.40 $0.00
23
Multnomah UnitedHealthcare
UnitedHealthcare Nursing Home Plan (PPO SNP) H2228 016
Local PPO Yes Institutional
Defined Standard Benefit $0.00 $28.70 $0.00
Multnomah UnitedHealthcare
UnitedHealthcare Assisted Living Plan (PPO SNP) H2228 017
Local PPO Yes Institutional
Basic Alternative $0.00 $24.90 $0.00
Multnomah FamilyCare Health
FamilyCare Community (HMO SNP) H3818 002 HMO Yes
Dual-Eligible
Enhanced Alternative $0.00 $31.40 $0.00
Multnomah CareOregon Advantage
CareOregon Advantage Plus (HMO-POS SNP) H5859 001 HMOPOS Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Multnomah Health Net Health Plan of Oregon, Inc.
Health Net Jade (HMO SNP) H6815 004 HMO Yes
Chronic or Disabling Condition
Enhanced Alternative $0.00 $0.00 $0.00
Multnomah Providence Health Assurance
Providence Medicare Dual Plus (HMO SNP) H9047 043 HMO Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Polk UnitedHealthcare
AARP MedicareComplete Plan 1 (HMO) H3805 001 HMO No
Enhanced Alternative $40.50 $26.50 $0.00
Polk UnitedHealthcare
AARP MedicareComplete Plan 2 (HMO) H3805 012 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Polk Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Polk
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO) H3817 008
Local PPO No
Basic Alternative $51.50 $49.50 $14.70
Polk
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO) H3817 009
Local PPO No
Enhanced Alternative $147.40 $66.90 $55.80
Polk Health Net Life Insurance Company
Health Net Violet Option 1 (PPO) H5520 002
Local PPO No
Enhanced Alternative $76.30 $39.70 $4.90
24
Polk Health Net Life Insurance Company
Health Net Violet Option 2 (PPO) H5520 012
Local PPO No
Basic Alternative $0.00 $32.00 $0.00
Polk
Regence BlueCross BlueShield of Oregon
Regence BlueAdvantage HMO (HMO) H6237 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Polk Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO) H6815 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Polk ATRIO Health Plans
ATRIO Gold Rx (Willamette) (PPO) H7006 001
Local PPO No
Enhanced Alternative $139.50 $45.50 $10.70
Polk ATRIO Health Plans
ATRIO Silver Rx (Willamette) (PPO) H7006 003
Local PPO No
Enhanced Alternative $54.10 $12.90 $0.00
Polk Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO) H9003 001 HMO No
Enhanced Alternative $61.00 $41.50 $31.20
Polk Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO) H9003 006 HMO No
Enhanced Alternative $14.70 $29.30 $0.00
Polk Providence Health Assurance
Providence Medicare Extra + RX (HMO) H9047 001 HMO No
Enhanced Alternative $109.10 $52.50 $18.10
Polk Providence Health Assurance
Providence Medicare Extra Part B Only + RX (HMO) H9047 013 HMO No
Enhanced Alternative $375.60 $42.10 $7.30
Polk Providence Health Assurance
Providence Medicare Choice + RX (HMO-POS) H9047 024 HMOPOS No
Enhanced Alternative $39.50 $48.50 $13.70
Polk ATRIO Health Plans
ATRIO Special Needs Plan (Willamette) (HMO SNP) H5995 001 HMO Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Sherman Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
25
Sherman PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO) H3864 006 HMO No
Enhanced Alternative $134.80 $50.30 $35.40
Sherman PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) H3864 014 HMOPOS No
Enhanced Alternative $73.80 $34.00 $19.20
Sherman PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO) H3864 027 HMO No
Basic Alternative $67.70 $54.30 $19.50
Sherman Moda Health Plan, Inc.
Moda Health HMO (HMO-POS) H8506 001 HMOPOS No
Enhanced Alternative $0.00 $63.00 $28.20
Tillamook Providence ElderPlace Portland
Providence ElderPlace Portland (dual eligible) (PACE) H3809 001
National PACE No $161.70 $0.00
Tillamook Providence ElderPlace Portland
Providence ElderPlace Portland (private pay) (PACE) H3809 002
National PACE No $125.50 $498.80
Tillamook Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Tillamook CareOregon Advantage
CareOregon Advantage Star (HMO-POS) H5859 003 HMOPOS No
Enhanced Alternative $0.00 $34.80 $0.00
Tillamook CareOregon Advantage
CareOregon Advantage Plus (HMO-POS SNP) H5859 001 HMOPOS Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Umatilla Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Umatilla Moda Health Plan, Inc.
Moda Health HMO (HMO-POS) H8506 001 HMOPOS No
Enhanced Alternative $0.00 $63.00 $28.20
26
Union Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Union Moda Health Plan, Inc.
Moda Health HMO (HMO-POS) H8506 001 HMOPOS No
Enhanced Alternative $0.00 $63.00 $28.20
Wallowa Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Wallowa Moda Health Plan, Inc.
Moda Health HMO (HMO-POS) H8506 001 HMOPOS No
Enhanced Alternative $0.00 $63.00 $28.20
Wasco Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Wasco PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO) H3864 006 HMO No
Enhanced Alternative $134.80 $50.30 $35.40
Wasco PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) H3864 014 HMOPOS No
Enhanced Alternative $73.80 $34.00 $19.20
Wasco PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO) H3864 027 HMO No
Basic Alternative $67.70 $54.30 $19.50
Washington Humana Medical Plan, Inc.
Humana Gold Plus H1036-153 (HMO) H1036 153 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Washington UnitedHealthcare
AARP MedicareComplete Choice (PPO) H2228 029
Local PPO No
Enhanced Alternative $2.50 $29.50 $0.00
Washington UnitedHealthcare
AARP MedicareComplete Plan 1 (HMO) H3805 001 HMO No
Enhanced Alternative $40.50 $26.50 $0.00
Washington UnitedHealthcare
AARP MedicareComplete Plan 2 (HMO) H3805 012 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
27
Washington Providence ElderPlace Portland
Providence ElderPlace Portland (dual eligible) (PACE) H3809 001
National PACE No $161.70 $0.00
Washington Providence ElderPlace Portland
Providence ElderPlace Portland (private pay) (PACE) H3809 002
National PACE No $125.50 $498.80
Washington Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Washington
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO) H3817 008
Local PPO No
Basic Alternative $2.00 $41.00 $6.20
Washington
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO) H3817 009
Local PPO No
Enhanced Alternative $106.40 $66.90 $55.80
Washington FamilyCare Health
FamilyCare Advantage Rx (HMO) H3818 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Washington PacificSource Medicare
PacificSource Medicare MyCare Rx 22 (HMO) H3864 022 HMO No
Enhanced Alternative $48.80 $29.20 $0.00
Washington Health Net Life Insurance Company
Health Net Violet Option 1 (PPO) H5520 002
Local PPO No
Enhanced Alternative $76.30 $39.70 $4.90
Washington Health Net Life Insurance Company
Health Net Violet Option 2 (PPO) H5520 012
Local PPO No
Basic Alternative $0.00 $19.00 $0.00
Washington CareOregon Advantage
CareOregon Advantage Star (HMO-POS) H5859 003 HMOPOS No
Enhanced Alternative $0.00 $34.80 $0.00
Washington
Regence BlueCross BlueShield of Oregon
Regence BlueAdvantage HMO (HMO) H6237 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Washington Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO) H6815 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
28
Washington Humana Insurance Company
Humana Gold Choice H8145-093 (PFFS) H8145 093 PFFS No
Enhanced Alternative $47.60 $34.90 $4.60
Washington Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO) H9003 001 HMO No
Enhanced Alternative $61.00 $41.50 $31.20
Washington Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO) H9003 006 HMO No
Enhanced Alternative $14.70 $29.30 $0.00
Washington Providence Health Assurance
Providence Medicare Extra + RX (HMO) H9047 001 HMO No
Enhanced Alternative $109.10 $52.50 $18.10
Washington Providence Health Assurance
Providence Medicare Extra Part B Only + RX (HMO) H9047 013 HMO No
Enhanced Alternative $375.60 $42.10 $7.30
Washington Providence Health Assurance
Providence Medicare Choice + RX (HMO-POS) H9047 024 HMOPOS No
Enhanced Alternative $39.50 $48.50 $13.70
Washington Providence Health Assurance
Providence Medicare Prime + RX (HMO-POS) H9047 037 HMOPOS No
Enhanced Alternative $0.00 $0.00 $0.00
Washington
AgeRight Advantage Health Plan (HMO SNP)
AgeRight Advantage Health Plan (HMO SNP) (HMO SNP) H1372 001 HMO Yes Institutional
Defined Standard Benefit $0.00 $30.40 $0.00
Washington UnitedHealthcare
UnitedHealthcare Nursing Home Plan (PPO SNP) H2228 016
Local PPO Yes Institutional
Defined Standard Benefit $0.00 $28.70 $0.00
Washington UnitedHealthcare
UnitedHealthcare Assisted Living Plan (PPO SNP) H2228 017
Local PPO Yes Institutional
Basic Alternative $0.00 $24.90 $0.00
Washington FamilyCare Health
FamilyCare Community (HMO SNP) H3818 002 HMO Yes
Dual-Eligible
Enhanced Alternative $0.00 $31.40 $0.00
29
Washington CareOregon Advantage
CareOregon Advantage Plus (HMO-POS SNP) H5859 001 HMOPOS Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Washington Health Net Health Plan of Oregon, Inc.
Health Net Jade (HMO SNP) H6815 004 HMO Yes
Chronic or Disabling Condition
Enhanced Alternative $0.00 $0.00 $0.00
Washington Providence Health Assurance
Providence Medicare Dual Plus (HMO SNP) H9047 043 HMO Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Wheeler Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Wheeler PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO) H3864 006 HMO No
Enhanced Alternative $134.80 $50.30 $35.40
Wheeler PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) H3864 014 HMOPOS No
Enhanced Alternative $73.80 $34.00 $19.20
Wheeler PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO) H3864 027 HMO No
Basic Alternative $67.70 $54.30 $19.50
Wheeler Moda Health Plan, Inc.
Moda Health HMO (HMO-POS) H8506 001 HMOPOS No
Enhanced Alternative $0.00 $63.00 $28.20
Wheeler Providence Health Assurance
Providence Medicare Latitude + RX (HMO-POS) H9047 038 HMOPOS No
Enhanced Alternative $111.60 $46.40 $22.60
Wheeler Providence Health Assurance
Providence Medicare Compass + RX (HMO-POS) H9047 039 HMOPOS No
Enhanced Alternative $59.70 $39.30 $4.50
Yamhill UnitedHealthcare
AARP MedicareComplete Choice (PPO) H2228 029
Local PPO No
Enhanced Alternative $2.50 $29.50 $0.00
30
Yamhill UnitedHealthcare
AARP MedicareComplete Plan 1 (HMO) H3805 001 HMO No
Enhanced Alternative $40.50 $26.50 $0.00
Yamhill UnitedHealthcare
AARP MedicareComplete Plan 2 (HMO) H3805 012 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Yamhill Moda Health Plan, Inc.
Moda Health PPORX (PPO) H3813 006
Local PPO No
Enhanced Alternative $40.60 $57.40 $22.60
Yamhill
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO) H3817 008
Local PPO No
Basic Alternative $51.50 $49.50 $14.70
Yamhill
Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO) H3817 009
Local PPO No
Enhanced Alternative $147.40 $66.90 $55.80
Yamhill Health Net Life Insurance Company
Health Net Violet Option 1 (PPO) H5520 002
Local PPO No
Enhanced Alternative $76.30 $39.70 $4.90
Yamhill Health Net Life Insurance Company
Health Net Violet Option 2 (PPO) H5520 012
Local PPO No
Basic Alternative $0.00 $24.00 $0.00
Yamhill CareOregon Advantage
CareOregon Advantage Star (HMO-POS) H5859 003 HMOPOS No
Enhanced Alternative $0.00 $34.80 $0.00
Yamhill Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO) H6815 003 HMO No
Enhanced Alternative $0.00 $0.00 $0.00
Yamhill Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO) H9003 001 HMO No
Enhanced Alternative $61.00 $41.50 $31.20
Yamhill Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO) H9003 006 HMO No
Enhanced Alternative $14.70 $29.30 $0.00
Yamhill Providence Health Assurance
Providence Medicare Extra + RX (HMO) H9047 001 HMO No
Enhanced Alternative $109.10 $52.50 $18.10
31
Yamhill
AgeRight Advantage Health Plan (HMO SNP)
AgeRight Advantage Health Plan (HMO SNP) (HMO SNP) H1372 001 HMO Yes Institutional
Defined Standard Benefit $0.00 $30.40 $0.00
Yamhill UnitedHealthcare
UnitedHealthcare Nursing Home Plan (PPO SNP) H2228 016
Local PPO Yes Institutional
Defined Standard Benefit $0.00 $28.70 $0.00
Yamhill UnitedHealthcare
UnitedHealthcare Assisted Living Plan (PPO SNP) H2228 017
Local PPO Yes Institutional
Basic Alternative $0.00 $24.90 $0.00
Yamhill CareOregon Advantage
CareOregon Advantage Plus (HMO-POS SNP) H5859 001 HMOPOS Yes
Dual-Eligible
Defined Standard Benefit $0.00 $34.80 $0.00
Yamhill Health Net Health Plan of Oregon, Inc.
Health Net Jade (HMO SNP) H6815 004 HMO Yes
Chronic or Disabling Condition
Enhanced Alternative $0.00 $0.00 $0.00