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Article Content
PEBB 2013 Full Time Medical Plans Comparison
(Available to both full time and part time PEBB-eligible employees)
This is a summary only. See plan documents for details.
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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 max |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Services |
In Network |
Out of Network |
In Medical Home 1 |
Out of Medical Home 1 |
Kaiser HMO |
Kaiser HMO |
Standard plan deductible 2 |
$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 |
$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 (deductibles, copays and some 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% |
30% |
$0 |
30% |
$5 |
$5 |
Specialty care visit |
15% |
30% |
$5 |
30% |
$5 |
$5 |
Mental health care |
Cost as for physical health services |
Cost as for physical health services |
Cost as for physical health services |
Cost as for physical health services |
Cost as for physical health services |
Cost as for physical health services |
| Subtance abuse treatment |
0% |
Cost as for physical/mental health services |
0% |
Cost as for physical/mental health services |
Cost as for physical/mental health services |
Cost as for physical/mental health services |
Maternity & childbirth provider services |
15% |
30% |
$0 |
30% |
$0/prenatal
Delivery services included in inpatient hospital |
$0/prenatal not subject to deductible
Delivery services included in inpatient hospital. |
Preventive |
$0 |
30% |
$0 |
30% |
$0 |
$0 |
Lab & X-ray |
15% |
30% |
$0 |
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 |
15% + $100 |
15% + $100 |
$100 |
$100 |
$75 |
$75 after deductible |
Durable medical equipment |
15% |
30% |
15% |
30% |
$0 |
15% |
Insulin and diabetic supplies |
$0 |
$0 |
$0 |
$0 |
$0 |
$0 |
Additional Cost Tier diagnostics7 |
15% +$100 |
30% +$100 |
$100 |
30% +$100 |
$100 copay8 |
$100 copay |
Additional Cost Tier procedures9 |
15% +$500 |
30%+$500 |
$500 |
30%+$500 |
Copay same as other conditions |
Copay same as other conditions |
Chiropractic, acupuncture, naturopathic |
30% coinsurance. 60 visits/yr max. In-network deductible applies. |
$10 copay; limited to lesser of $1000
or 60 visits/yr |
$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
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Vision |
VSP Provider |
Non-VSP Provider |
VSP Provider |
Non-VPS Provider |
$5 exam copay.
$200 hardware allowance max/24 months. |
$5 exam copay.
$200 hardware allowance max/24 months. |
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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. |
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. 2 All 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 covered services. Deductibles apply per individual, based on the employee’s choice of coverage tier. The maximum number of individuals in a family who must meet the deductible is three. 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). These are not subject to the deductible: first four visits per individual to a primary care provider; insulin and diabetic supplies; in plan 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-person 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 participate by completing their health assessment by Oct. 31, 2012. This deductible works the same as the standard plan deductible, as described in 2 above.
4 Members whose in-network provider has been certified 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 and coinsurance amounts for a use of a hospital emergency department are waived if the member is admitted to the hospital for inpatient treatment. This does not include inpatient admittance for observation. Copay does not apply to out-of-pocket maximum. In-plan deductible applies. 7 These diagnostic procedures are MRI, CT, PET and SPECT scans; sleep studies; and upper endoscopy. Copay does not apply to out-of-pocket maximum. These procedures may be overused compared with their risks and benefits. Additional copay does not apply to cancer-related procedures. 8 Upper endoscopy is not on the Additional Cost Tier in 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. Spine injections for pain are also on this tier, but with a $100 copay. Copay does not apply to out-of-pocket maximum. Additional copay does not apply to cancer-related procedures. 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, with a family (three-person) maximum of $150. It applies separately from any other deductible. 11 The $1,000 out-of-pocket maximum for prescription drugs applies per person in the plan, with a family (three-person) maximum of $3,000. 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 2013 Part Time Medical Plans Comparison
(Available only to part time PEBB-eligible employees)
This is a summary only. See plan documents for details.
Download a PDF |
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 (deductibles, copays and some 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 |
$30 |
50% subject to deductible |
$30 |
$30 |
Specialty care visit |
20% |
50% |
$30 |
30% |
$30 |
$30 |
Mental health care |
Cost as for physical health services |
Cost as for physical health services |
Cost as for physical health services |
Cost as for physical health services |
Cost as for physical health services |
Cost as for physical health services |
| Substance Abuse Treatment |
0% |
Cost as for physical/mental health services |
0% |
Cost as for physical/mental health services |
Cost as for physical/mental health services |
Cost as for physical/mental health services |
Maternity & childbirth provider services |
20% |
50% |
$0 |
50% |
$0/prenatal
Delivery services included in inpatient hospital |
$0/prenatal
Delivery services included in inpatient hospital. Not subject to deductible |
Preventive |
$0 |
50% |
$0 |
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 |
20% + $100 |
20% + $100 |
20% + $100 |
$100 |
$100 |
$100 after deductible |
Durable medical equipment |
20% |
50% |
20% |
50% |
50% |
50% |
Insulin/diabetic supplies |
$0 |
$0 |
$0 |
$0 |
20% (insulin covered as prescription drug) |
20% (insulin covered as prescription drug) |
Additional Cost Tier Diagnostics7 |
20% +$100 |
50% +$100 |
20% +$100 |
50% +$100 |
$1008 |
$1008 |
Additional Cost Tier Surgical Procedures9 |
20% +$500 |
50%+$500 |
$500 |
30%+$500 |
Copay same as other conditions |
Copay same as other conditions |
Chiropractic, acupuncture, naturopathic |
50% applies to in-network deductible 60 visits/yr max |
$50 applies to in-network deductible.
Limited to lesser of $1000
or 60 visits/yr |
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 maximum11
$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
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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 |
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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 in that medical home (In Medical Home) or through providers referred by their medical home. Otherwise, benefits are Out of Medical Home with have higher costs. 2 All plans (except the Kaiser HMO) have a standard plan deductible. This is the amount a member must pay for covered services before the plan begins to pay its share for covered services. Deductibles apply per individual, based on the employee’s choice of coverage tier. The maximum number of individuals in a family who must meet the deductible is three. Payments toward the deductible accumulate separately for services provided by In Network and Out of Network providers and for services provided by In Medical Home and Out of Medical Home providers. These are not subject to the deductible: first four visits per individual to a primary care provider; insulin and diabetic supplies; in plan visits for care of asthma, diabetes, cardiovascular disease or congestive heart failure; preventive care 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. A $100-per-person Non-HEM deductible, with a family (three-person) maximum of $300, will be added to the health plan’s standard deductible for members who choose not to sign up for the HEM program or who sign up but don’t participate by completing their Step 1 health assessment as scheduled. This HEM deductible is in addition to the health plan’s standard deductible (both in-network and out-of-network). Deductibles apply per individual, based on the employee’s choice of coverage tier. 4 Members whose provider has been certified by the Oregon Health Authority as providing 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. 6 Copay and coinsurance amounts for a use of a hospital emergency department are waived if the member is admitted to the hospital for inpatient treatment. This does not include inpatient admittance for observation. 7 These diagnostic procedures are MRI, CT, PET and SPECT scans; sleep studies; and upper endoscopy. These procedures may be overused compared with their risks and benefits. Additional copay does not apply to cancer-related procedures. 8 Upper endoscopy is not on the Additional Cost Tier in 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. Spine injections for pain are also on this tier but with a $100 copay. Additional copay does not apply to cancer-related procedures. 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, with a family (three-person) maximum of $150. It applies separately from any other deductible and accumulates separately for prescriptions filled by In Network and Out of Network providers.
11 The $1,000 out-of-pocket maximum for prescription drugs applies per person in the plan, with a family (three-person) maximum of $3,000. 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. |
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