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PEBB 2014 Full Time Medical Plans Comparison
 
Available to full time and part time PEBB-eligible employees
This is a summary provided as a convenience in comparing plans. See the plan’s governing document for details.
PEBB Statewide
Providence Choice
Kaiser HMO
Kaiser Deductible
Plan’s service Area
Statewide and Nationwide
Clackamas, Clark, Coos, Curry, Deschutes, Hood River, Jefferson, Lane, Linn-Benton, Marion-Polk, Multnomah, Wallawa, Washington, Yamhill counties (updates soon)1
Zip codes in Benton, Clackamas, Clark, Columbia, Hood River, Linn, Marion, Multnomah, Polk, Washington and Yamhill counties
Lifetime max
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Services
In Network
Out of Network
In Medical Home1
Out of Medical Home 1
Kaiser HMO
Kaiser HMO
Standard plan deductible 2 (Applies to all services unliess otherwise noted)
$250/individual
$750/family
Four primary care visits not subject
$500/individual
$1500/family
$250/individual $750/family
Four primary care visits not subject
$500/individual
$1500/family
$0
$250/individual
$750/family. Office visits, some services not subject
Added deductible for HEM Non-Participants 3 (Applies to all services unless otherwise noted)
$100/individual $300 family
$100/individual $300 family
$100/individual $300 family
$100/individual $300 family
$100/individual $300 family
$100/individual $300 family
Out-of-pocket max (some deductibles, copays, services don’t apply)
$1500/individual $4500/family
$2500/individual $7500/family
$1500/individual $4500/family
$2500/individual $7500/family
$600/individual $1200/family
$1500/individual $4500/family
Primary care visit
15% or 10%4
30%
$5
30%
$5
$5
Chronic care visit5
0% deductible waived
30%
$0 deductible waived
30%
$5
$5
Specialty care visit
15%
30%
$5
30%
$5
$5
Mental health care
Same as other medical services
Same as other medical services
Same as other medical services
Same as other medical services
Cost as for physical health services
Cost as for physical health services
Subtance abuse treatment 0%​ deductible waived
Same as other medical services
0%​ deductible waived Same as other medical services No member cost No member cost
Maternity & childbirth provider services
$0/prenatal
15% /delivery
30%
$0 /prenatal
$0/delivery
30%
$0/prenatal
Delivery services included in inpatient hospital
$0/prenatal not subject to deductible
Delivery services included in inpatient hospital.
Preventive
0% deductible waived
30%
$0 deductible waived
30%
$0
$0
Lab & X-ray
15%
30%
$0 deductible waived
30%
$0
$15
Inpatient hospital
15%
30%
$50/day to $250
30%
$50/day up to $250 max/admission
$50/day to $250 max/admission after deductible
Emergency dept.6
$100 + 15%
$100 + 15%
$100
$100
$75
$75 after deductible
Durable medical equipment
15%
30%
15%
30%
$0
15%
Insulin and diabetic supplies
0% deductible waived
0% deductible waived
$0 deductible waived
$0 deductible waived
$0
$0
Additional Cost Tier $100 copay7
$100 + 15%
$100 + 30%
$100
$100 + 30%
$100 copay8
$100 copay
Additional Cost Tier $500 copay9
$500 + 15%
$500 + 30%
$500
$500 + 50%
Copay same as other conditions
Copay same as other conditions
Spinal manipulation, acupuncture 30% coinsurance. In network deductible applies. To 60 services/yr combined​ ​
$10 copay up to $1,000/yr.
In network deductible applies.
$10 up to $1000/yr $10 up to $1000/yr
Alternative care visit
30% coinsurance. In-network deductible applies.
$10 copay. In network duductible applies.
$10 up to $1000/yr
$10 up to $1000/yr
Prescription Drugs
In Network
Out of Network
In network
Out of Network
Kaiser HMO
Kaiser HMO
$50 deductible $1000 out-of-pocket maximum10
Retail: $0 Value
(not subject to deductible)11 $10 generic
$30 brand
$100 specialty
Copay x 2.5 for 90-day
Urgent, emergent and out-of country.
In-network deductible, out-of-pocket maximum apply. Reimbursed as if filled in network; member pays difference between network & billed amount
$50 deductible10
$1000 out-of-pocket maximum10$0 Value
(not subject to deductible)12 $10 generic.
$30 brand
$100 specialt.
Copay x 2.5 for 90-day
Urgent, emergent and out-of country.
In-network deductible, out-of-pocket maximum apply. Reimbursed as if filled in network; member pays difference between network & billed amount
No deductible
No out-of-pocket maximum
$1 generic
$15 brand
Maintenance
(31-90 day)
$1 generic
$15 brand
No deductible
No out-of-pocket maximum
$5 generic
$25 brand
Maintenance
(31-90 day)
$5 generic
$25 brand
50% to $100 for exception-
approved non-
formulary
 
 
Vision
VSP Provider
Non-VSP Provider
VSP Provider
Non-VPS Provider
Kaiser HMO
Kaiser HMO 
Annual benefit $10 exam copay.
$25 frame copay.
$150 retail frame allowance.
Single and lined bifocal and trifocal lenses covered in full. Progressive lenses available at 35-40% discount
Or
$200 allowance for contacts and contacts fitting/evaluation.
Annual benefit
Exam reimbursement up To $50 after $10 copay.
Frame reimbursement up to $70 after $25 copay.
Reimbursement of $50 to $100 for single and lined bifocal and trifocal lenses.
Or reimbursement up to $105 for contacts.
Annual benefit
$10 exam copay.
$25 frame copay.
$150 retail frame allowance.
Single and lined bifocal and trifocal lenses covered in full.
Progressive lenses available at 35-40% discount.
Or
$200 allowance for contacts and contacts fitting/evaluation.
Annual benefit
Exam reimbursement up To $50 after $10 copay.
Frame reimbursement up to $70 after $25 copay.
Reimbursement of $50 to $100 for single and lined bifocal and trifocal lenses.
Or reimbursement up to $105 for contacts.

$5 exam copay. $200 hardware allowance max/24 months.

For members 18 and younger, $5 exam copay, no charge for hardware once every 24 months.

$5 exam copay. $200 hardware allowance max/24 months.
For members 18 and younger, $5 exam copay, no charge for hardware once every 24 months.
 
1 To receive Medical Home benefits, members must choose a medical home in the plan, notify Providence of their choice, and receive care through providers from that medical home (In Medical Home) or from providers referred by their medical home. Otherwise, benefits are Out of Medical Home with higher costs. See the full list of medical homes here ProvidenceHealthPlan.com/pebbmedicalhomes. More medical home clinics may be added throughout Open Enrollment.
2 All medical plans have a standard plan deductible (except Kaiser HMO). This is the amount a member must pay for covered services before the plan begins to pay its share for medically necessary covered services. Deductibles apply per individual, or the family deductible will apply when there are 3 or more individuals within a family, based on the employee’s choice of coverage tier. Payments toward the deductible accumulate separately for services In Network and Out of Network, and In Medical Home and Out of Medical Home (see 1 above). In network services not subject to the deductible: first four visits per individual to a primary care provider; insulin and diabetic supplies; visits for care of asthma, diabetes, cardiovascular disease or congestive heart failure; and preventive services.
3 The goal of the Health Engagement Model (HEM) program is to engage as many people as possible in improving their health, which can help to contain health care costs over time. A $100-per individual HEM Non-Participant deductible will be added to their plan’s standard deductible for members who choose not to sign up for the HEM program or who sign up but don’t complete their health assessment within the scheduled timeframe, or who don’t actively enroll in 2014 benefits. This HEM deductible is in addition to the plan’s standard deductible (both in-network and out-of-network).This deductible works the same as the standard plan deductible, as described in 2 above.
4 PEBB Statewide plan members whose in-network provider has been recognized by the Oregon Health Authority as a Patient-Centered Primary Care Home will have the lower, 10% coinsurance.
5 These are visits for care of asthma, diabetes, cardiovascular disease and congestive heart failure. Not subject to deductible in network.
6 Copay amounts for use of a hospital emergency department are waived if the member is admitted directly to the hospital for inpatient treatment. This does not include admittance for observation. Copay does not apply to out-of-pocket maximum except in Kaiser plans. In-plan deductible applies.
7 These procedures are MRI, CT, PET and SPECT scans; sleep studies; spinal injections; upper endoscopy; bunionectomy; surgery for hammertoe and Morton’s neuroma; and knee viscosupplementation. Copay does not apply to out-of-pocket maximum except in Kaiser plans. Not applied to cancer-related procedures. These procedures may be overused compared with their risks and benefits.
8 Upper endoscopy is not on the Additional Cost Tier in the Kaiser plans.
9 These are surgical procedures for hip or knee replacement or resurfacing; knee or shoulder arthroscopy; bariatric surgery; spine procedures; and sinus surgery. Copay does not apply to out-of-pocket maximum except in Kaiser plans. Not applied to cancer treatment. These procedures may have alternatives that provide equal or better outcomes with lower risks and costs.
10 The prescription-drug deductible is $50 per person or $150 for families with 3 or more members. It applies separately from the medical deductible.
11 The prescription-drug out-of-pocket maximum is $1,000 per person, with a family (three-person) maximum of $3,000. It accrues separately from the medical out-of-pocket maximum.
12 All plans have formularies that list covered drugs. Value drugs in Providence’s formulary typically are generic drugs that are used in treating most common chronic conditions.
 
 
PEBB 2014 Part time Time Medical Plans Comparison
 
Available only to part time PEBB-eligible employees
This is a summary provided as a convenience in comparing plans. See the plan’s governing document for details.
 
PEBB Statewide
Providence Choice
Kaiser HMO
Kaiser Deductible
Plan’s service Area
Statewide and Nationwide
Clackamas, Clark, Coos, Curry, Deschutes, Hood River, Jefferson, Lane, Linn-Benton, Marion-Polk, Multnomah, Wallawa, Washington and Yamhill counties
Zip codes in Benton, Clackamas, Clark, Columbia, Hood River, Linn, Marion, Multnomah, Polk, Washington and Yamhill counties
Lifetime maximum
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Services
In Network
Out of Network
In Medical Home1
Out of Medical Home1
Kaiser HMO
Kaiser HMO
Standard plan deductible2
$500/individual
$1500/family
Four primary care visits not subject
$1000/individual
$3000/family
$500/individual
$1500/family
Four primary care visits not subject
$1000/individual
$3000/family
$0
$250/individual
$750/family Office visits and some services not subject
Added deductible for HEM non-participation3
$100/individual $300 family
$100/individual $300 family
$100/individual $300 family
$100/individual $300 family
$100/individual $300 family
$100/individual $300 family
Out-of-pocket max (some deductibles, copays, services don’t apply)
$2500/individual $7500/family
$4500/individual $13500/family
$2500/individual $7500/family
$4500/individual $13500/family
$1500/individual $3000/family
$1500/individual $4500/family
Primary care visit
20% or 15%4
50%
$30
50%
$30
$30
Chronic care visit5
0%
50% subject to deductible
$0
50% subject to deductible
$30
$30
Specialty care visit
20%
50%
$30
30%
$30
$30
Mental health care
Same as other medical services
Same as other medical services
Same as other medical services
Same as other medical services
Same as other medical services
Same as other medical services
Substance Abuse Treatment 0%​ deductible waived
Same as other medical services
$0 deductible waived
Same as other medical services
$0
Same as other medical services
Maternity & childbirth provider services
$0/prenatal
20%/delivery
50%
$0/prematal
20%/delivery
50%
$0/prenatal
Delivery services included in inpatient hospital
$0/prenatal
Delivery services included in inpatient hospital. Not subject to deductible
Preventive
0% deductible waived
50%
$0 deductible waived
50%
$0
$0
Lab & X-ray
20%
50%
20%
50%
$10
$20
Inpatient hospital
20%
50%
$500/admission
50%
$500/admission
$500/admission after deductible
Emergency department6
$100 + 20%
$100 + 20%
$100
$100
$100
$100 after deductible
Durable medical equipment
20%
50%
20%
50%
50%
50%
Insulin/diabetic supplies
$0 deductible waived
$0 deductible waived
$0 deductible waived
$0 deductible waived
20% (insulin covered as prescription drug)
20% (insulin covered as prescription drug)
Additional Cost Tier $100 copay7
$100 + 20%
50% +$100
$100
50% +$100
$1008
$1008
Additional Cost Tier Surgical Procedures9
20% +$500
$500 + 50%
$500
$500 + 50%
Copay same as other conditions
Copay same as other conditions
​Spinal manipulation, acupuncture 50% coinsurance. In-network deductible applies. To 60 services per year combined ​​50% coinsurance. In-network deductible applies. To 60 services per year combined ​Not covered ​Not covered
Aternative care visit
50% coinsurance. In-network deductible applies
$50 copay. In-network deductible applies.
Not covered
Not covered
Prescription Drugs
In Network
Out of Network
In network
Out of Network
Kaiser HMO
Kaiser HMO
$50/individual, $150/family deductible10
$1000 out-of-pocket maximum0.83en
 
$0 Value
(not subject to deductible)12
$20 generic
40% preferred brand
$100 specialty
Copay x 2.5 for 90-day
Urgent, emergent and out-of country.
In-network deductible and out-of-pocket maximum apply. Reimbursed as if filled in network; member pays difference between network & billed amount
$50/individual, $150/family deductible10$1000 out-of-pocket maximum11
$0 Value
(not subject to deductible)12
$20 generic
$50 preferred brand
$100 specialty
Copay x 2.5 for 90-day
Urgent, emergent and out-of country.
In-network deductible and out-of-pocket maximum apply. Reimbursed as if filled in network; member pays difference between network & billed amount
No deductible
No out-of-pocket maximum
$10 generic
$25 brand
Mail order two copays for up to 90 day-supply
No deductible
No out-of-pocket maximum
$10 generic
$25 brand
Mail order two
copays for up to
90-day supply
 
 
Vision
VSP Provider
Non-VSP Provider
VSP Provider
Non-VPS Provider
$30 exam copay
No other vision coverage
$30 exam copay
No other vision coverage
The VSP full time vision plan is available to retirees as a separate policy. Vision not covered for all other enrollees in this plan
The VSP full time vision plan is available to retirees as a separate policy. Vision not covered for all other enrollees in this plan
The VSP full time vision plan is available to retirees as a separate policy. Vision not covered for all other enrollees in this plan
The VSP full time vision plan is available to retirees as a separate policy. Vision not covered for all other enrollees in this plan

1 To receive Medical Home benefits, members must choose a medical home in the plan, notify Providence of their choice, and receive care through providers from that medical home (In Medical Home) or from providers referred by their medical home. Otherwise, benefits are Out of Medical Home with higher costs. See the full list of medical homes here ProvidenceHealthPlan.com/pebbmedicalhomes. More medical home clinics may be added throughout Open Enrollment.
2 All medical plans have a standard plan deductible (except Kaiser HMO). This is the amount a member must pay for covered services before the plan begins to pay its share for medically necessary covered services. Deductibles apply per individual, or the family deductible will apply when there are 3 or more individuals within a family, based on the employee’s choice of coverage tier. Payments toward the deductible accumulate separately for services In Network and Out of Network, and In Medical Home and Out of Medical Home (see 1 above). In network services not subject to the deductible: first four visits per individual to a primary care provider; insulin and diabetic supplies; visits for care of asthma, diabetes, cardiovascular disease or congestive heart failure; and preventive services.
3 The goal of the Health Engagement Model (HEM) program is to engage as many people as possible in improving their health, which can help to contain health care costs over time. A $100-per individual HEM Non-Participant deductible will be added to their plan’s standard deductible for members who choose not to sign up for the HEM program or who sign up but don’t complete their health assessment within the scheduled timeframe, or who don’t actively enroll in 2014 benefits. This HEM deductible is in addition to the plan’s standard deductible (both in-network and out-of-network).This deductible works the same as the standard plan deductible, as described in 2 above.
4 PEBB Statewide plan members whose in-network provider has been recognized by the Oregon Health Authority as a Patient-Centered Primary Care Home will have the lower, 15% coinsurance.
5 These are visits for care of asthma, diabetes, cardiovascular disease and congestive heart failure. Not subject to deductible in network.
6 Copay amounts for use of a hospital emergency department are waived if the member is admitted directly to the hospital for inpatient treatment. This does not include admittance for observation. Copay does not apply to out-of-pocket maximum except in Kaiser plans. In-plan deductible applies.
7 These procedures are MRI, CT, PET and SPECT scans; sleep studies; spinal injections; upper endoscopy; bunionectomy; surgery for hammertoe and Morton’s neuroma; and knee viscosupplementation. Copay does not apply to out-of-pocket maximum except in Kaiser plans. Not applied to cancer-related procedures. These procedures may be overused compared with their risks and benefits.
8 Upper endoscopy is not on the Additional Cost Tier in the Kaiser plans.
9 These are surgical procedures for hip or knee replacement or resurfacing; knee or shoulder arthroscopy; bariatric surgery; spine procedures; and sinus surgery. Copay does not apply to out-of-pocket maximum except in Kaiser plans. Not applied to cancer treatment. These procedures may have alternatives that provide equal or better outcomes with lower risks and costs.
10 The prescription-drug deductible is $50 per person or $150 for families with 3 or more members. It applies separately from the medical deductible.
11 The prescription-drug out-of-pocket maximum is $1,000 per person, with a family (three-person) maximum of $3,000. It accrues separately from the medical out-of-pocket maximum.
12 All plans have formularies that list covered drugs. Value drugs typically are generic drugs that are used in treating most common chronic conditions.