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EMPLOYER NAME: KITTITAS COUNTY <br />ELECTIONSECTION V: PLAN <br />MEDICAL PLANS <br />Directions: Enter X for 4 -tiered rates or C for composite rate (subject to carrier approval). <br />If offering both Premera Blue Cross and Group Health plans, the SAME rate structure must be used. <br />Note: All medical plans are bundled with base long term disability and an Employee Assistance Program (EAP). <br />1. PREMERA BLUE CROSS ......................................... ® CHECK TO DECLINE COVERAGE <br />The number of plans available to an organization is based on the group's total number of eligible employees. <br />Employer groups may offer one Health Savings Account (HSA) plan in addition to the number of plan choices. <br />a) Under 50 eligible employees: Up to 2 plan choices <br />b) 50 - 150 eligible employees: Up to 3 plan choices <br />c) 150+ eligible employees: Up to 4 plan choices <br />Select Network Option: <br />CWCIF 200* <br />LEOFF I Active <br />1 1 WCIF 200 <br />J LEOFF I Retiree <65 <br />1-1 Heritage <br />F-1WCIF 500 <br />FWCIF 2000 <br />F-1 Prime <br />l WCIF 750 <br />nWCIF 3000 <br />�I WCIF 1250 <br />__ WCIF 5000 <br />F—IWCIF HSA** <br />* Only available to groups with enrollment prior to 1/1/2014. <br />** Groups may offer a Health Savings Account (HSA) with the WCIF HSA Plan. This is a Qualified High Deductible Health <br />Plan (QHDHP). <br />11. GROUP HEALTH ................................................ ® CHECK TO DECLINE COVERAGE <br />The number of plans available to an organization is based on the group's total number of eligible employees. <br />Employer groups may offer plan choices as allowed under the Group Health matrix. <br />ACCESS PPO PLANS: <br />Access 200 <br />Access 3000 <br />1-1 Access 500 <br />ElAccess 5000 <br />El LEOFF I Retiree < 65 <br />� Access 1000 <br />FAccess HSA* <br />❑ Access 2000 <br />* Groups may offer a Health Savings Account (HSA) with the HSA Plan. This is a Qualified High Deductible Health <br />Plan (QHDHP). <br />HMO PLANS: <br />HMO 250 F-1 HMO 500 <br />JHMO 750 1 HMO 2000 <br />1-1 LEOFF I Retiree < 65 <br />2017GMA2 Page 4 of 9 (0921161sw) <br />