To meet the state’s ongoing financial crisis and ensure quality care for PEBB members, your Benefit Board has introduced changes to plan designs for 2012. This is a high-level summary only. The Board will meet Aug. 26 and 30 to finalize plan designs and premium rates.
Members can choose to enroll in a HEM plan as their contribution to managing the group’s costs in 2012. Or they can enroll in the same basic plan design but without HEM and pay $30 per month ($45 for employee and spouse or partner) as their contribution to controlling costs. Note: The Board changed these amounts to $20 and $35 during its meeting on Aug. 26, 2011.
Weight Watchers coverage
The plans will cover the cost of participation in Weight Watchers for covered spouses and domestic partners as well as the principal subscriber.
The first four visits with a primary care provider will have reduced member share, as will office visits for certain chronic conditions.
Members will pay out of pocket for covered services until they reach the plan deductible. The individual deductible is $250 when using in-network providers and $500 when using out-of-network providers. Corrected 09/13/11: The family deductible (three or more people) is $750 in-network and $1,500 out-of-network. Amounts accumulate separately for use of in- and out-of-network providers.
After a member has paid the out-of-pocket maximum, the plan fully covers eligible
claims. The maximum will be $1,500 per individual, $4,500 per family (more than
Prescription drug coverage
Prescription coverage will have a $50-per-person deductible. Plan formularies will have four copay tiers:
Value drugs $0
Generic drugs $10
Brand formulary drugs $30
Specialty drugs $100
Existing exceptions to copays for non-formulary drugs will no longer be valid beginning Jan. 1, 2012.
Waiving other coverage
Members who cover a spouse or domestic partner will pay a $50 monthly surcharge when the spouse or domestic partner waives coverage in a non-state-agency employer’s group plan in favor of coverage through PEBB.
Members and spouses or domestic partners who currently use tobacco will pay a $25-per-user monthly surcharge. Note: Beginning 2013, premiums for optional life insurance will be tobacco-rated based on member use of tobacco in the prior 12 months (from November 2011 forward).
Plans will no longer cover surgical procedures for the following: removal of common warts; TMJ syndrome; varicose veins; breast-reduction; and ganglion cysts, bunions, corns, hammer toe and non-cancerous neuroma.
Additional cost tier
Plans will require an additional copay for partial hip and knee replacement, SPECT imaging and sinus surgery. Copays on this tier don’t apply to the annual out-of-pocket maximum or the annual deductible.