2018 Employee Medical Plan Monthly Premium …

1 2 Public Employees Benefit Board 2018 Enrollment GuideMedicalChoose your 2018 health planHigher-cost Medical plans have higher Employee Premium shareThe higher-cost plans with higher Premium share are both the full-time and part-time Kaiser HMO and PEBB Statewide PPO Medical plans. The lower-cost plans with lower Premium share are the following full-time and part-time Medical plans: Kaiser Deductible, Moda Summit, Moda Synergy and Providence Choice. At least one higher-cost and one lowercost plan is available in each to Standard Tiers2018 is the second year in the three year process to align our coverage tiers with those of other large employers.

2 This will protect our plans from an impending federal excise tax. The process requires annual increases to premiums for the Employee and Family tier to 2021. We will use the Stabilization Fund to subsidize the Employee share of these increases. The tables below show the Monthly Premium rate by tier for each of the Medical plans. Part-time employees who choose a part-time plan have a subsidy. The subsidy is not shown in the Premium rate. It is included in the cost estimator at Employee Medical plan Monthly Premium Rates (available to both full-time and part-time employees) EmployeeEmployee & Spouse/PartnerEmployee & ChildrenEmployee & FamilyKaiser1$ $1, $1, $2, Kaiser Deductible1$ 6 5 $1, $1, $1, Moda Summit, Synergy2$ $1, $ 1,14 2.

3 24 $1, PEBB Statewide3 $ 7 5 7. 0 8 $1, $ 1, 2 8 7. 0 5 $ 2 ,0 4 Providence Choice4$ $1, $1, $ 1,74 6 . 5 3 1 Available to PEBB eligible full-time and part-time employees in plan service area. Kaiser routine vision Available to PEBB eligible full-time and part-time employees in plan service Available to PEBB eligible full-time and part-time Available to PEBB eligible full-time and part-time employees in plan service Part-time Employee Medical plan Monthly Premium Rates (available only to part-time employees) EmployeeEmployee & Spouse/PartnerEmployee & ChildrenEmployee & FamilyKaiser5$ $1, 2 $1, $1,70 3 Kaiser Deductible5$ $ 1,10 7.

4 5 5 $ 9 $1, Moda Summit, Synergy6$ 5 4 7. 0 3 $1,0 9 6 $ $1, 8 PEBB Statewide7 $ $1,23 6 $1, $1, Providence Choice8$ $1, $ 8 9 $1, 4 5 Additional option available to eligible part-time employees in plan service Additional option available to eligible part-time employees in plan service Additional option available to eligible part-time Additional option available to eligible part-time employees in plan service Employees Benefit Board 2018 Enrollment Guide 3 MedicalMedical plansHealth Plans by oregon CountyThis table shows the higher-cost and lower-cost plans available in each county.

5 A part-time version of each of these plans with an employer subsidy is available to part-time employees. Full-time employees cannot enroll in part-time Summit, Providence ChoicePEBB StatewideBentonKaiser Deductible, Moda Synergy, Providence ChoiceKaiser HMO, PEBB StatewideClackamasKaiser Deductible, Moda Synergy, Providence ChoiceKaiser HMO, PEBB StatewideClatsopModa Synergy, Providence ChoicePEBB StatewideColumbiaKaiser Deductible, Moda SynergyKaiser HMO, PEBB StatewideCoosModa Synergy, Providence ChoicePEBB StatewideCrookModa Synergy, Providence ChoicePEBB StatewideCurryModa Synergy, Providence ChoicePEBB StatewideDeschutesModa Synergy.

6 Providence ChoicePEBB StatewideDouglasModa Synergy, Providence ChoicePEBB StatewideGilliamModa SummitPEBB StatewideGrantModa Summit, Providence ChoicePEBB StatewideHarneyModa Summit, Providence ChoicePEBB StatewideHood RiverModa Synergy, Providence ChoicePEBB StatewideJacksonModa Synergy, Providence ChoicePEBB StatewideJeffersonModa Synergy, Providence ChoicePEBB StatewideJosephineModa Synergy, Providence ChoicePEBB StatewideKlamathModa Synergy, Providence ChoicePEBB StatewideLakeModa SummitPEBB StatewideLaneModa Synergy, Providence ChoicePEBB StatewideLincolnModa Synergy, Providence ChoicePEBB StatewideLinnKaiser Deductible, Moda Synergy, Providence ChoiceKaiser HMO, PEBB StatewideMalheurModa Summit, Providence ChoicePEBB StatewideMarionKaiser Deductible, Moda Synergy, Providence ChoiceKaiser HMO, PEBB StatewideMorrowModa Summit, Providence ChoicePEBB StatewideMultnomahKaiser Deductible, Moda Synergy, Providence ChoiceKaiser HMO, PEBB StatewidePolkKaiser Deductible, Moda Synergy, Providence ChoiceKaiser HMO, PEBB StatewideShermanModa SummitPEBB StatewideTillamookModa Synergy, Providence ChoicePEBB StatewideUmatillaModa Summit.

7 Providence ChoicePEBB StatewideUnionModa Summit, Providence ChoicePEBB StatewideWallowaModa Summit, Providence ChoicePEBB StatewideWascoModa Synergy, Providence ChoicePEBB StatewideWashingtonKaiser Deductible, Moda Synergy, Providence ChoiceKaiser HMO, PEBB StatewideWheelerModa Summit, Providence ChoicePEBB StatewideYamhillKaiser Deductible, Moda Synergy, Providence ChoiceKaiser HMO, PEBB StatewideThis is a summary only. See the plan documents for details. In the case of a discrepancy, the plan document will apply. See footnotes, page Public Employees Benefit Board 2018 Enrollment GuideMedicalMedical plansKaiser Permanente NW Area: Benton, Clackamas, Columbia, Hood River, Linn, Marion, Multnomah, Polk, Washington and Yamhill.

8 Clark, Cowlitz, Lewis, Skamania & Wahkiakum WAFull-timePart-timeStandard deductible2$250/individual, $750/family Some services not subject to deductible$250/individual, $750/family Some services not subject to deductibleAdditional non-HEM participant deductible3 Additional deductible: $100/individual, $300/family applies to all services unless otherwise notedOut-of-pocket max$1500/individual $4500/family$1500/individual, $4500/familyProvidersKaiser Permanente network of providersReferralsReferrals to non-Kaiser Permanente providers only from Kaiser providerPrimary care visit$5, deductible waived$30, deductible waivedChronic care visit5$5, deductible waived$30, deductible waivedSpecialty visit$5 w/referral, deductible waived$30 w/referral, deductible waivedOutpatient mental health care$5, deductible waived$30, deductible waivedSubstance abuse treatment$0.

9 Deductible waived$0, deductible waivedPrenatal, first postnatal visit$0, deductible waived$0, deductible waivedDeliveryInpatient delivery subject to inpatient hospital chargesPreventive$0, deductible waived$0, deductible waivedLab & X-ray$15, deductible waived$20, deductible waivedInpatient hospital per admission$50/day up to $250 max$500 Emergency department6$75$100 Durable Medical equipment15%, deductible waived50%, deductible waivedInsulin & diabetic supplies$0 or 0%, deductible wavedAdditional Cost Tier $100 copay8$100 copay, deductible waived$100 copay, deductible waivedAdditional Cost Tier $500 copayStandard copay only, applies to out of pocket maximumStandard copay only, applies to out of pocket maximumAlternative care provider visits13$10, deductible waived$30, with physician s authorization referral, deductible waivedSpinal manipulation, acupuncture services13$10, deductible waived$30 with physician s authorization referral, deductible waivedPrescription drugsNo deductibleCopays accumulate to out-of-pocket maximum$5 generic$25 brand50% up to $100 max non-formulary brand$50 SpecialtyMail order (31-90 day)

10 , $5 generic, $25 formulary brand, 50% up to $100 max non-formulary brandNo deductibleCopays accumulate to out-of-pocket maximum$10 generic$25 brand$50 SpecialtyMail order 2 copays for up to 90-day supplyThis is a summary only. See the plan documents for details. In the case of a discrepancy, the plan document will apply. See footnotes, page Employees Benefit Board 2018 Enrollment Guide 5 MedicalMedical plansKaiser Permanente NW Area: Benton, Clackamas, Columbia, Hood River, Linn, Marion, Multnomah, Polk, Washington and Yamhill; Clark, Cowlitz, Lewis, Skamania & Wahkiakum WAFull-timePart-timeStandard deductible$0$0 Additional HEM non-participant deductible3 Additional deductible.