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2012 and 2013 Medical Plans Comparisons
Full Time Plans
 
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.
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[i]
Out of Medical Home[i]
 Kaiser HMO
Kaiser HMO
Standard plan deductible[ii]
$250/individual
$750/family
Four primary care visits not subject
$500/individual
$1500/family Four primary care visits not subject
$250/individual $750/family
Four primary care visits not subject
$500/individual
$1500/family Four primary care visits not subject
$0
$250/individual
$750/family. Office visits, some services not subject
Added deductible for HEM Non-Participants[iii]
$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%[iv]
30%
$5
30%
$5
$5
Chronic care visit[v]
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
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.[vi]
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 diagnostics[vii]
15% +$100
30% +$100
$100
30% +$100
$100 copay[viii]
$100 copay
Additional Cost Tier procedures[ix]
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[x]
$1000 out-of-pocket  maximum[xi]
Retail: $0 Value
(not subject to deductible)[xii]
$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  maximum[xi]
$0 Value
(not subject to deductible)
[xii]
$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
$5 exam copay.
$200 hardware allowance max/24 months.
$5 exam copay.
$200 hardware allowance max/24 months.
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.


[i] 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.
[ii] 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.
[iii]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.
[iv] 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.
[v] These are visits for care of asthma, diabetes, cardiovascular disease and congestive heart failure. Not subject to deductible in network. 
[vi] 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.
[vii] 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.
[viii] Upper endoscopy is not on the Additional Cost Tier in Kaiser plans.
[ix] 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.
[x] The prescription-drug deductible is $50 per person, with a family (three-person) maximum of $150. It applies separately from any other deductible.
[xi] 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. 
[xii] 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 2012 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.
 
Click here to download a PDF copy
   
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/individual deductible (not applied to Value) to $150/family
$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/individual deductible (not applied to Value) to $150/family
$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, applies to in-network deductible
60 visits/yr max
$10 copay, applies to in-network deductible, 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: The Providence Choice and Statewide plans have a prescription drug deductible of $50 per person, up to $150 per family (three individuals).Deductibles accumulate separately in and out of network. Value drugs aren't subject to the deductible. 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 surgery for warts, varicose vein surgery (including radio frequency ablation), varicose vein stripping, TMJ surgery, surgery for ganglions of the wrist, surgery for Morton’s neuroma, hammertoe surgery, bunionectomy surgery and breast reduction surgery. Surgery for certain varicose vein conditions may be considered for prior authorization. Kaiser HMO and Kaiser Deductible (full- and part-time) plan members will pay a copay, as for treatment of other conditions.

 
Part Time Plans
 
 
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 Home[i]
Out of Medical Home1
 Kaiser HMO
Kaiser HMO
Standard plan deductible[ii]
$500/individual
$1500/family
Four primary care visits not subject
$1000/individual
$3000/family Four primary care visits not subject
$500/individual
$1500/family
Four primary care visits not subject
$1000/individual
$3000/family Four primary care visits not subject
$0
$250/individual
$750/family Office visits and some services not subject
Added deductible for HEM non-participation[iii]
$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%[iv]
50%
$30
50%
$30
$30
Chronic care visit[v]
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
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 department[vi]
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 Diagnostics[vii]
20% +$100
50% +$100
20% +$100
50% +$100
$100[viii]
$1008
Additional Cost Tier Surgical Procedures[ix]
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 deductible[x]
$1000 out-of-pocket  maximum[xi]
$0 Value
(not subject to deductible)[xii]
$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 deductible[x]
$1000 out-of-pocket  maximum[xi]
$0 Value
(not subject to deductible)
[xii]
$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


[i] 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.
[ii] 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.
[iii]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.
[iv] 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.
[v] These are visits for care of asthma, diabetes, cardiovascular disease and congestive heart failure. 
[vi] 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.
[vii] 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.
[viii] Upper endoscopy is not on the Additional Cost Tier in Kaiser plans.
[ix] 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.
[x] 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.
[xi] 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.
[xii] 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 2012 Part Time Medical Plans Comparison
(Available only to part time PEBB-eligible employees)
This is a summary only. See plan documents for details.
 
 
Click here to download a PDF copy
  
 
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/individual deductible (not applied to Value)to $150/family
$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/individual deductible (not applied to Value)to $150/family
$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, applies to in-network deductible
60 visits/yr max
50% copayment, applies to in-network deductible, 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: The Providence Choice and Statewide plans have a prescription drug deductible of $50 per person, up to $150 per family (three individuals). Deductibles accumulate separately in and out of network. Value drugs aren't subject to the deductible. 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 surgery for warts, varicose vein surgery (including radio frequency ablation), varicose vein stripping, TMJ surgery, surgery for ganglions of the wrist, surgery for Morton’s neuroma, hammertoe surgery, bunionectomy surgery and breast reduction surgery. Surgery for certain varicose vein conditions may be considered for prior authorization. Kaiser HMO and Kaiser Deductible (full- and part-time) plan members will pay a copay, as for treatment of other conditions.