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2012 Medical Plan Comparisons
Full Time Plans
Download and Print a PDF (11X17)
 
This is a summary only. See plan documents for details
 
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.

Part Time Plans
 
Download and Print a PDF (11x17)
 
This is a summary only. See plan documents for details.
 
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.