Public Employees' Benefit Board 2012 and 2013 Medical Plans Comparisons

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Public Employees' Benefit Board

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.

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 max

Unlimited

Services

In Network

Out of Network

In Medical Home[i]

Out of Medical Home^[i]

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

$250/individual

$750/family. Office visits, some services not subject

Added deductible for HEM Non-Participants[iii]

$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%

Chronic care visit[v]

30%

Specialty care visit

15%

30%

Mental health care

Cost as for physical health services

Maternity & childbirth provider services

15%

30%

$0/prenatal

Delivery services included in inpatient hospital

$0/prenatal not subject to deductible

Delivery services included in inpatient hospital.

Preventive

30%

Lab & X-ray

15%

30%

$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

$100

$75

$75 after deductible

Durable medical equipment

15%

30%

15%

30%

15%

Insulin and diabetic supplies

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

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

Prescription Drugs

In Network

Out of Network

In network

Out of Network

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

$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.

$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

Services

In Network

Out of Network

In Medical Home[i]

Out of Medical Home¹

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

$250/individual

$750/family Office visits and some services not subject

Added deductible for HEM non-participation[iii]

$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

Chronic care visit[v]

50% subject to deductible

$30

50% subject to deductible

$30

Specialty care visit

20%

50%

$30

30%

$30

Mental health care

Cost as for physical health services

Maternity & childbirth provider services

20%

50%

$0/prenatal

Delivery services included in inpatient hospital

$0/prenatal

Delivery services included in inpatient hospital. Not subject to deductible

Preventive

50%

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

$100

$100 after deductible

Durable medical equipment

20%

50%

20%

50%

Insulin/diabetic supplies

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

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

Prescription Drugs

In Network

Out of Network

In network

Out of Network

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

[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.

[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.

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