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EMPLOYER NAME: KITTITAS COUNTY <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. PREMIERA 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 />WCIF 200* <br />❑ LEOFF I Active <br />❑WCIF 200 <br />LEOFF I Retiree <65 <br />1-1 Heritage <br />[ WCIF 500 <br />WCIF 2000 <br />* Only available to groups with enrollment prior to 1/1/2014. <br />F-x, Prime <br />F -X1 WCIF 750 <br />i <br />X WCIF 3000FX I <br />WCIF 1250 <br />WCIF 5000 <br />EWCIF HSA** <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 />ElAccess 200 u Access 500 1XI Access 1000 Access 2000 <br />FAccess 3000 Access 5000 1 X I Access HSA* <br />1:1� LEOFF I Retiree < 65 <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 />CHMO 250 <br />HHMO 500 FX- HMO 750 HMO 2000 <br />LEOFF I Retiree < 65 <br />2017GMA2 Page 4 of 9 (0921161sw) <br />