Benefits apply without regard to HEM participation¹

PEBB Statewide Plan

Providence Choice

Kaiser HMO

Kaiser Deductible Plan

Service Area

Statewide and Nationwide

Clackamas, Clark, Curry, Deschutes, Lane, Linn-Benton, Marion-Polk, Multnomah, Washington and Yamhill counties

Zip codes in Benton, Clackamas, Clark, Columbia, Hood River, Linn, Marion, Multnomah, Polk, Washington and Yamhill counties

Provider Status

In Network

Out of Network

In Network

Out of Network

Kaiser Permanente

Kaiser Permanente

Deductible²

$250/individual
$750/family
4 primary care visits not subject

$500/individual
$1500/family
4 primary care visits not subject

$250/individual
$750/family
4 primary care visits not subject

$500/individual
$1500/family
4 primary care visits not subject

$0

$250/individual
$750/family
office visits and some services not subject

Lifetime Maximum

Unlimited

Unlimited

Unlimited

Unlimited

Unlimited

Unlimited

Out-of-Pocket Maximum³

$1500/individual
$4500/family

$2500/individual
$7500/family

$1500/individual
$4500/family

$2500/individual
$7500/family

$600/individual
$1200/family

$1500/individual
$4500/family

Spouse/Domestic Partner Surcharge⁴

$50/month

$50/month

$50/month

$50/month

$50/month

$50/month

Tobacco Surcharge⁵

$25/month/employee
$25/spouse/domestic partner

$25/month/employee
$25/spouse/domestic partner

$25/month/employee
$25/spouse/domestic partner

$25/month/employee
$25/spouse/domestic partner

$25/month/employee
$25/spouse/domestic partner

$25/month/employee
$25/spouse/domestic partner

Primary Care

15%

30%

$5

30%

$5

$5

Chronic Care Office Visit

0%

30% subject to deductible

$0

30% subject to deductible

$5

$5

Specialty Care

15%

30%

$5

30%

$5

$5

Mental Health

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

Maternity/Childbirth Provider Services

15%

30%

$0

30%

$0/prenatal, $50/day;

up to $250 maximum/admission

$0/prenatal; $50/day;

up to $250 maximum per admission. Prenatal not subject to deductible; deductible does apply to maternity/childbirth

Preventive

$0

30%

$0

30%

$0

$0

Lab & X-ray

15%

30%

$0

30%

$0

$15

MRI, CT, PET, SPECT

15% + $100

30% + $100

$100

30% + $100

$100

$100

Sleep Study

15% + $100

30% + $100

$100

30% + $100

$100

$100

Inpatient Hospital

15%

30%

$50/day;

up to $250 maximum per admission

30%

$50/day;

up to $250 maximum per admission

$50/day;

up to $250 maximum after deductible

Emergency Department

15% + $100

15% + $100

$100

$100

$75

$75, after deductible has been met

Durable Med Equipment

15%

30%

15%

30%

$0

15%

Insulin/Diabetic Supplies

$0

$0

$0

$0

$0

$0

Prescription Drugs⁶

$50 deductible (not applied to Value)

$0 Value

$10 generic

$30 preferred brand

$100 specialty

2.5X for 90-day

No tier exceptions

Paid as if filled in network; Member pays difference between network & billed amt + coinsurance 2.5X for 90-day

$50 deductible (not applied to Value)

$0 Value

$10 generic

$30 preferred brand

$100 specialty

2.5X for 90-day

No tier exceptions

Paid as if filled in network; Member pays difference between network & billed amt + coinsurance 2.5X for 90-day

$1 generic/$15 brand

$1 generic 31-90 day maintenance mail order

$15 brand 31-90 day maintenance mail order

$5 generic / $25 brand

$50/50% whichever is greater for exception-approved non-formulary drugs

$5 generic 31-90 day maintenance mail order

$25 brand 31-90 day maintenance mail order

Vision

$10 exam copay
$25 frame copay
$150 retail frame allowance
Single and lined bifocal and trifocal lenses covered in full
Progressive lenses available at a 35-40% discount.
Or $200 allowance for contacts and contacts fitting/evaluation

VSP reimburses exam to $50 office copay
$70 frame allowance
$50-$125 single and lined bi or trifocal lenses allowance
Progressive lenses available at a 35-40% discount
Contact lenses covered in full to $105 if elective, $210 if necessary

$10 exam copay
$25 frame copay
$150 retail frame allowance
Single and lined bifocal and trifocal lenses covered in full
Progressive lenses available at a 35-40% discount.
Or $200 allowance for contacts and contacts fitting/evaluation

VSP reimburses exam to $50
$70 frame allowance
$50-$125 single and lined bi or trifocal lenses allowance
Progressive lenses available at a 35-40% discount
Contact lenses covered in full to $105 if elective, $210 if necessary

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

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

Chiropractic, Acupuncture, Naturopathic Services

30% coinsurance
60 visits/yr max

$10 copay
limited to the lesser of $1000 or 60 visits/yr

$10 up to $1000/yr

$10 up to $1000/yr

Additional-cost Tier (does not apply to cancer related services)

Hip replacement

Knee replacement

Knee arthroscopy

Shoulder arthroscopy

Bariatric Surgery

Spine pain procedures

Sinus surgery

Knee/Hip resurfacing

Hip arthroplasty

15% + $500

30% + $500

$500

30% + $500

Copay same as other conditions

Copay same as other conditions

Upper endoscopy

15% + $100

30% + $100

$100

30% + $100 copay

Copay same as other conditions

Copay same as other conditions

Excluded Services⁷

1 Benefits and HEM: The benefits shown here apply in or out of the Health Engagement Model (HEM) program. Employees (and spouses or domestic partners) who participate in HEM will have $20 (or $35) per month less deducted from their pay. NOTE: A PEBB-eligible employee must participate in the HEM program to allow a spouse or domestic partner to participate. A spouse or domestic partner of a PEBB-eligible employee may not participate in the HEM program as an individual if the employee does not.

 

² Deductibles: In the Statewide and Providence Choice plans, the deductible does not apply to the first 4 visits to a primary care provider, preventive services, or the out-of-pocket maximum; however, the coinsurance applies even if the deductible does not. The deductible applies to all specialty visits and all lab and x-ray services. Once 3 members of family have met their individual deductible, all in-network services for all members of the family will be paid as if their individual in-network deductible has been met. Deductible amounts accumulate separately in these plans when using in-network and out-of-network providers. The Kaiser Health Maintenance Organization (HMO) plan has no deductible. In the Kaiser Deductible plan, office visits and some other services do not apply to the deductible. See the plan’s evidence of coverage or call Kaiser Member Services. In this plan, once 3 members of family have met their individual deductible, all in-network services for all members of the family will be paid as if their individual in-network deductible has been met.

 

³ Annual Out-of-Pocket (OOP) Maximums: In the Statewide and Providence choice plans, once 3 members of a family have met their individual $1500 in-network OOP, all in-network services for all members of the family will be paid as if their individual in-network OOP has been met; once 3 members of a family have met their individual $2500 out-of-network OOP, all out-of-network services for all members of the family will be paid as if their individual out-of-network OOP has been met. In the Kaiser HMO, once 2 members of a family have met their individual $600 OOP, all in-plan services for all members of the family will be paid as if their individual in-network OOP has been met. In the Kaiser Deductible Plan, once 3 members of a family have met their individual $1500 in-network OOP, all in-plan services for all members of the family will be paid as if their individual in-network OOP has been met.

 

⁴ Spouse or Domestic Partner Coverage Surcharge: A $50 monthly surcharge is applied if an employee’s spouse or domestic partner has access to other non-Oregon-state-agency employer-based group health insurance and chooses not to enroll.

 

⁵ Tobacco Surcharge: A $25 monthly surcharge is applied to employees and covered spouses or domestic partners who use tobacco as stated when they enroll.

 

⁶ Prescription Drugs: See the plans’ formularies, which list drugs covered in the plan and how they are covered.

 

⁷ Excluded Services: PEBB Statewide and Providence Choice (full- and part-time) plan members will pay 100% of the cost for excluded services. Beginning 2012, these include treatment of warts, varicose vein surgery, varicose vein stripping, TMJ surgery, ganglion surgery, neuromas surgery, hammertoe surgery, bunionectomy, breast reduction and radio frequency ablation. Kaiser HMO and Kaiser Deductible (full- and part-time) plan members will pay a copay, as for treatment other conditions.

Benefits apply without regard to HEM participation¹

Part-Time PEBB Statewide Plan

Part-Time Providence Choice

Part-Time Kaiser HMO

Part-Time Kaiser Deductible Plan

Service Area

Statewide and Nationwide

Clackamas, Clark, Curry, Deschutes, Lane, Linn-Benton, Marion-Polk, Multnomah, Washington and Yamhill counties

Zip codes in Benton, Clackamas, Clark, Columbia, Hood River, Linn, Marion, Multnomah, Polk, Washington and Yamhill counties

Provider Status

In Network

Out of Network

In Network

Out of Network

Kaiser Permanente

Kaiser Permanente

Deductible²

$500/individual
$1500/ family
4 primary care visits not subject

$1000/individual
$3000/family
4 primary care visits not subject

$500/individual
$1500/ family
4 primary care visits not subject

$1000/individual
$3000/family
4 primary care visits not subject

$0

$250/individual
$750/Family
office visits and some services not subject

Lifetime Maximum

Unlimited

Unlimited

Unlimited

Unlimited

Unlimited

Unlimited

Out-of-Pocket Maximum³

$2500/individual
$7500/family

$4500/individual
$13500/family

$2500 individual
$7500/family

$4500/individual
$13500/family

$1500/individual
$3000/family

$1500/individual
$4500/family

Spouse or Domestic Partner Surcharge⁴

$50/month

$50/month

$50/month

$50/month

$50/month

$50/month

Tobacco Surcharge⁵

$25/month/employee
$25/spouse/domestic partner

$25/month/employee
$25/spouse/domestic partner

$25/month/employee
$25/spouse/domestic partner

$25/month/employee
$25/spouse/domestic partner

$25/month/employee
$25/spouse/domestic partner

$25/month/employee
$25/spouse/domestic partner

Primary Care

20%

50%

$30

50%

$30

$30

Chronic Care Office Visit

$0

50% subject to deductible

$0

50% subject to deductible

$30

$30

Specialty Care

20%

50%

$30

50%

$30

$30

Mental Health

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

Maternity/Childbirth Provider Services

20%

50%

$0

50%

$0/prenatal; up to $500 maximum per admission

$0/prenatal; $500 per admission. Prenatal not subject to deductible; deductible does apply to maternity/childbirth

Preventive

0%

50%

$0

50%

$0

$0

Lab & X-ray

20%

50%

20%

50%

$10

$20

MRI, CT, PET, SPECT

20% + $100

50% + $100

20% + $100

50% + $100

$100

$100

Sleep Study

20% + $100

50% + $100

20% + $100

50% + $100

$100

$100

Inpatient Hospital

20%

50%

$500/admission

50%

$500 per admission

$500 per admission, after deductible

Emergency Department

20% + $100

20% + $100

$100

$100

$100

$100, after deductible

Durable Med 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)

Prescription Drugs⁶

$50 deductible (not applied to Value drugs)

$0 Value

$20 generic/$40 preferred brand

$100 specialty

2.5X for 90-day

No tier exceptions

PD as if filled in network; Member pays difference between network & billed amt + coinsurance

2.5X for 90-day

$50 deductible (not applied to Value drugs)

$0 Value

$20 generic/$50 preferred brand

$100 specialty

2.5X for 90-day

No tier exceptions

PD as if filled in network; Member pays difference between network & billed amt + coinsurance

2.5X for 90-day

$10 generic

$25 brand

$20 generic and $50 brand 31-90 day maintenance mail order

$10 generic

$25 brand

$20 generic and $50 brand 31-90 day maintenance mail order

Vision

The VSP full time vision plan is available to retirees as a separate policy. Vision not covered for all other enrollees

The VSP full time vision plan is available to retirees as a separate policy. Vision not covered for all other enrollees

The VSP full time vision plan is available to retirees as a separate policy. Vision not covered for all other enrollees

The VSP full time vision plan is available to retirees as a separate policy. Vision not covered for all other enrollees

$30 exam copay, hardware not covered

$30 exam copay, hardware not covered

Chiropractic, Acupuncture, Naturopathic Services

50% coinsurance
60 visits/yr max

50%; limited to the lesser of $1000 or 60 visits/yr

not covered

not covered

Additional-cost Tier (does not apply to cancer related services)

Hip replacement

Knee replacement

Knee arthroscopy

Shoulder arthroscopy

Bariatric Surgery

Spine pain procedures

Sinus surgery

Knee/Hip resurfacing

Hip arthroplasty

20% + $500

50% + $500

$500

50% + $500

Copay same as other conditions

Copay same as other conditions

Upper endoscopy

20% + $100

50% + $100

$100 copay

50% + $100 copay

Copay same as other conditions

Copay same as other conditions

Excluded Services⁷

 

1 Benefits and HEM: The benefits shown here apply in or out of the Health Engagement Model (HEM) program. Employees (and spouses or domestic partners) who participate in HEM will have $20 (or $35) per month less deducted from their pay. NOTE: A PEBB-eligible employee must participate in the HEM program to allow a spouse or domestic partner to participate. A spouse or domestic partner of a PEBB-eligible employee may not participate in the HEM program as an individual if the employee does not.

 

² Deductibles: In the Statewide and Providence Choice plans, the deductible does not apply to the first 4 visits to a primary care provider, preventive services, or the out-of-pocket maximum; however, the coinsurance applies even if the deductible does not. The deductible applies to all specialty visits and all lab and x-ray services. Once 3 members of family have met their individual deductible, all in-network services for all members of the family will be paid as if their individual in-network deductible has been met. Deductible amounts accumulate separately in these plans when using in-network and out-of-network providers. The Kaiser Health Maintenance Organization (HMO) plan has no deductible. In the Kaiser Deductible plan, office visits and some other services do not apply to the deductible. See the plan’s evidence of coverage or call Kaiser Member Services. In this plan, once 3 members of family have met their individual deductible, all in-network services for all members of the family will be paid as if their individual in-network deductible has been met.

 

³ Annual Out-of-Pocket (OOP) Maximums: In the Statewide and Providence choice plans, once 3 members of a family have met their individual $1500 in-network OOP, all in-network services for all members of the family will be paid as if their individual in-network OOP has been met; once 3 members of a family have met their individual $2500 out-of-network OOP, all out-of-network services for all members of the family will be paid as if their individual out-of-network OOP has been met. In the Kaiser HMO, once 2 members of a family have met their individual $600 OOP, all in-plan services for all members of the family will be paid as if their individual in-network OOP has been met. In the Kaiser Deductible Plan, once 3 members of a family have met their individual $1500 in-network OOP, all in-plan services for all members of the family will be paid as if their individual in-network OOP has been met.

 

⁴ Spouse or Domestic Partner Coverage Surcharge: A $50 monthly surcharge is applied if an employee’s spouse or domestic partner has access to other non-Oregon-state-agency employer-based group health insurance and chooses not to enroll.

 

⁵ Tobacco Surcharge: A $25 monthly surcharge is applied to employees and covered spouses or domestic partners who use tobacco as stated when they enroll.

 

⁶ Prescription Drugs: See the plans’ formularies, which list drugs covered in the plan and how they are covered.

 

⁷ Excluded Services: PEBB Statewide and Providence Choice (full- and part-time) plan members will pay 100% of the cost for excluded services. Beginning 2012, these include treatment of warts, varicose vein surgery, varicose vein stripping, TMJ surgery, ganglion surgery, neuromas surgery, hammertoe surgery, bunionectomy, breast reduction and radio frequency ablation. Kaiser HMO and Kaiser Deductible (full- and part-time) plan members will pay a copay, as for treatment other conditions.