The Confederated Tribes of Grand Ronde Employee Health Plan PPO Network: Varies by State Oregon and Washington Residents: First Choice Health Network (FCHN) Prescription Network: Optum RX

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Deductible

The fixed dollar amount you must pay each plan year before benefits subject to the annual deductible become available. You cannot pay the annual deductible amount to us in advance. You must meet the deductible on a claim by claim basis.

*Medical Coverage Amount Individual $500

Individual NON-PPO $1,500

Family PPO $1,500

Family NON-PPO NONE

*Deductible waived if Grand Ronde is secondary PPO and NON-PPO deductibles feed each other.

**Dental Coverage Amount Individual $50

Family $150

**Deductible waived when coordinating benefits with primary insurance.

Out-of-Pocket Maximum

The maximum deductible, copayment, and coinsurance amounts you pay in a plan year. Once you meet the coinsurance maximum you are no longer responsible for deductible, copayment, or coinsurance amounts.

Medical Coverage Participating Provider Non-Participating Provider Individual $5,000 No Limit

Family $10,000 No Limit

Prescription RX Coverage Participating Pharmacy Non-Participating Pharmacy Individual $1,600 No Limit

Family $3,200 No Limit

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Please refer to the Shasta Portal for additional benefits and eligibility information. In the case of a discrepancy between this page and the language contained within the portal, the latter will take precedence. Registration and login are required for portal access.